Linda Perkins-Porras

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.

Triggering of acute coronary syndromes by physical exertion and anger: clinical and sociodemographic characteristics

Objective: To investigate the role of vigorous physical exertion and anger as triggers of acute coronary syndromes (ACS) and to identify the clinical and sociodemographic correlates of triggering. Design: Prospective observational clinical cohort study. Setting: Four coronary care units in the London area. Patients: 295 men and women with electrocardiographically and biochemically verified ACS. Main outcome measures: Physical exertion in the 1 h and anger in the 2 h before symptom onset were assessed with structured interviews. Control periods were the equivalent hours one day earlier and usual rates over the past six months. Data were analysed by case-crossover methods. Results: Physical exertion was reported by 10% and anger by 17.4% of patients in the hazard period. The risk of ACS onset after physical exertion compared with light or no activity was 3.50 (95% confidence interval (CI) 1.37 to 10.6). The risk of onset with anger was 2.06 (95% CI 1.12 to 3.92). Physical exertion during the hazard period was related to an absence of premonitory symptoms, presentation with an ST elevation myocardial infarction (STEMI), low socioeconomic deprivation and higher future cardiovascular risk. Anger during the hazard period was more common in younger, socioeconomically deprived patients who presented with a STEMI. Conclusions: Triggers are relevant across the spectrum of ACS. The distinct clinical and sociodemographic factors associated with physical exertion and anger suggest that different pathophysiological processes may be involved.

Psychological and social predictors of changes in fruit and vegetable consumption over 12 months following behavioral and nutrition education counseling.

This study assessed psychological and social factors predicting 12-month changes in fruit and vegetable consumption achieved by 271 men and women from a low-income population randomized to brief behavioral and nutrition education counseling. Greater increases in fruit and vegetable intake were achieved in the behavioral than in the nutrition education condition (1.49 vs. 0.87 portions per day, p=.021). Increases were predicted by baseline social support for dietary change but not by baseline psychological measures. However, short-term (8-week) changes in dietary self-efficacy, encouragement, anticipated regret, perceived benefits, and knowledge of recommended intake predicted 12-month changes in fruit and vegetable consumption independently of gender, age, ethnicity, income, and baseline intake. These factors accounted for 51% of the superiority of behavioral counseling over nutrition education.

Psychological Factors Associated With Fruit and Vegetable Intake and With Biomarkers in Adults From a Low-Income Neighborhood

Fruit and vegetable consumption is below recommended levels in the population, paricularly in low-income groups. This study assessed factors associated with self-reported intake and 2 biomarkers (potassium excretion and plasma vitamin C) in 271 adults living in a low-income neighborhood. Attitudinal barriers to change were negatively related to reported intake and to potassium excretion. Poor knowledge of recommended consumption was associated with low reported intake, low potassium excetion, and low plasma vitamin C concentration. Self-efficacy was related to reported intake but not to biomarkers. The authors conclude that several of the psychological factors associated with self-reported intake were also related to biomarkers in this population and that these may therfore be particularly appropriate targets for intervention.

Pre-hospital delay in patients with acute coronary syndrome: Factors associated with patient decision time and home-to-hospital delay

Background: Pre-hospital delays in patients experiencing acute coronary syndromes (ACS) remain unacceptably long. Aims: To examine simultaneously a wide range of clinical, sociodemographic and situational factors associated with total pre-hospital delay and its two components. Methods: Pre-hospital delay data were collected from 228 patients with ACS using patients medical notes and semi-structured interviews. Total pre-hospital delay (symptom onset to hospital admission) was divided into 2 components: decision time (symptom onset to call for medical help), and home-to-hospital delay (call for help to hospital admission). Results: Shorter total pre-hospital delays and decision times were associated with ST segment myocardial infarction (STEMI), recognizing symptoms as cardiac in origin, being married, symptom onset outside the home and the presence of a bystander. Shorter home-to-hospital delays were more likely among younger patients, those experiencing an STEMI, and patients reporting a greater number of symptoms. Initial contact with emergency medical services was related to shorter total delays and decision times. Conclusions: Different factors were associated with shorter times in the 2 component phases. Greater understanding of the factors impacting on the component phases may help target interventions more effectively and reduce pre-hospital delays.

Type-D personality and cortisol in survivors of acute coronary syndrome.

Objective: To test the hypothesis that Type-D personality is associated with elevated cortisol levels in patients 4 months after an acute coronary syndrome (ACS). Methods: Salivary cortisol profiles were measured at home in 70 coronary heart disease patients (Mean age = 60.90 years, SD = 10.7, 17% female) 4 months after hospitalization for ACS. Eight saliva samples were taken over the course of 1 day. Results: Thirty eight percent of the ACS patients were defined as Type-D. Cortisol profiles showed a typical diurnal pattern, with low levels in the evening, high levels early in the day. Type-D was not related to the cortisol awakening response, but cortisol output the day was higher in Type-D (mean = 4443.3, SD = 2334.1 nmol/l) than non Type-D patients (mean = 3252.0, SD = 1810.2 nmol/l) after adjustment for age, gender, hypertension, Global Registry of Acute Coronary Events risk score, recurrence of cardiac symptoms, previous myocardial infarction, body mass index and concurrent depressed mood (p = .044). Type-D personality accounted for 6% over the variance in cortisol output over the day, after covariates had been taken into account. Conclusion: Type-D personality may be associated with prolonged disruption of the hypothalamic-pituitary-adrenal axis function in survivors of acute cardiac events and may contribute to biological responses influencing future cardiac morbidity. MI = myocardial infarction; BMI = body mass index; ACS = acute coronary syndrome; CAR = cortisol awakening response; HPA = hypothalamic-pituitary-adrenal axis; SD = standard deviation; GRACE = global registry of acute coronary events.

Acute depressed mood as a trigger of acute coronary syndromes.

BACKGROUND Some cases of acute coronary syndrome (ACS) may be triggered by emotional states such as anger, but it is not known if acute depressed mood can act as a trigger. METHODS 295 men and women with a verified ACS were studied. Depressed mood in the two hours before ACS symptom onset was compared with the same period 24 hours earlier (pair-matched analysis), and with usual levels of depressed mood, using case-crossover methods. RESULTS 46 (18.2%) patients experienced depressed mood in the two hours before ACS onset. The odds of ACS following depressed mood were 2.50 (95% confidence intervals 1.05 to 6.56) in the pair-matched analysis, while the relative risk of ACS onset following depressed mood was 4.33 (95% confidence intervals 3.39 to 6.11) compared with usual levels of depressed mood. Depressed mood preceding ACS onset was more common in lower income patients (p = .032), and was associated with recent life stress, but was not related to psychiatric status. CONCLUSIONS Acute depressed mood may elicit biological responses that contribute to ACS, including vascular endothelial dysfunction, inflammatory cytokine release and platelet activation. Acute depressed mood may trigger potentially life-threatening cardiac events.

Social networks and partner stress as predictors of adherence to medication, rehabilitation attendance, and quality of life following acute coronary syndrome.

OBJECTIVE This study examined whether social network size and partner stress predicted medication adherence, cardiac rehabilitation attendance, and quality of life 12 months following hospitalization for an acute coronary syndrome (ACS). DESIGN ACS patients (N = 193, M age = 60.6 years, SD = 11.4 years, 23% female) were recruited shortly following admission to 4 local hospitals. A prospective design was employed with follow-up data collected 12 months following hospital admission. MAIN OUTCOME MEASURES Data were gathered on social network size and partner stress. The main outcomes assessed at 12 months were medication adherence, cardiac rehabilitation attendance, and quality of life (Short Form 36). RESULTS Partner stress predicted medication nonadherence, odds ratio: 2.89, (95% CI = 1.21, 6.95). ACS patients with large social networks were more likely to attend rehabilitation, odds ratio: 3.42, (95% CI = 1.42, 8.25). Analyses were adjusted for age, gender, clinical risk scores, readmission/recurrence, and negative affectivity. Both partner stress and smaller social network size were associated with poorer quality of life. CONCLUSION Social network size and partner stress may partly exert their influence on coronary heart disease morbidity and mortality through recovery behaviors and maintenance of quality of life.

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.

Quality of life and self-rated health in relation to changes in fruit and vegetable intake and in plasma vitamins C and E in a randomised trial of behavioural and nutritional education counselling

We have carried out a randomised trial comparing brief behavioural counselling with nutritional education counselling to increase fruit and vegetable consumption and associated biomarkers in adults from a low-income neighbourhood. The objective of the present analysis was to assess the impact of interventions on quality of life and health status, and associations between changes in fruit and vegetable consumption, plasma vitamins C and E, and quality of life. Behavioural counselling and nutritional education counselling were carried out in 271 adults in two 15 min sessions in a primary-care setting. Physical and mental health status (medical outcome study short form 36) and self-rated health were assessed at baseline, 8 weeks and 12 months, and analysed on an intention-to-treat basis. Both groups reported increased fruit and vegetable consumption; plasma vitamin E and beta-carotene also increased, with significantly greater changes in consumption and plasma beta-carotene in the behavioural counselling condition. Physical and mental health status, and the proportion of participants in good self-rated health, increased in both groups to a similar extent. Individual differences in improvements in physical health status and self-rated health were correlated with increases in fruit and vegetable intake and in plasma vitamins C and E, independently of age, gender, ethnicity, financial status, smoking, BMI and use of vitamin supplements. We conclude that participation in the present study was associated with improved health-related quality of life. Increases in fruit and vegetable intake and plasma vitamin levels may stimulate beneficial changes in physical health status in socio-economically deprived adults.