Lynn V. Doering

Depression as a Risk Factor for Poor Prognosis Among Patients With Acute Coronary Syndrome: Systematic Review and Recommendations A Scientific Statement From the American Heart Association

Background— Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome. Methods and Results— Writing group members were approved by the American Heart Association’s Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes. Conclusions— Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

Strategies for Improving Survival After In-Hospital Cardiac Arrest in the United States: 2013 Consensus Recommendations A Consensus Statement From the American Heart Association

The goal of this statement is to develop consensus recommendations aimed at measuring and optimizing outcomes after in-hospital cardiac arrest (IHCA). For the purposes of this statement, IHCA is defined as a cardiac arrest that occurs in a hospital (whether the patient is admitted or not) and for which resuscitation is attempted with chest compressions, defibrillation, or both. Members of the writing group were selected for their expertise in cardiac resuscitation and post–cardiac arrest care. Monthly telephone conferences and “webinars” over a 10-month period were used to define the scope of the statement and to assign writing teams for each section. The first draft of each section was discussed and sent to the chair to be compiled into a single document. Revised versions were then sent to all writing group members until consensus was achieved. The final draft underwent 3 sets of independent peer review before publication. The American Heart Association (AHA) is committed to the highest ethical standards. The AHA believes that having experts who have a relationship with industry or other relevant relationships on writing groups can strengthen the writing group effort when these relationships are transparent and managed. The AHA conflict of interest policy requires each member to declare relevant and current conflicts of interest. The chair may not have any relationship with industry relevant to the topic. The majority of writing group members (defined as>50% +1) must be free of relevant relationships with industry. Every writing group member agrees to maintain his or her current status with respect to relationships with industry throughout the development of the manuscript to publication. In addition, each member formally declares his or her conflict of interest or relationship with industry at the time of publication. All members of this writing group were compliant with this policy (“Writing Group Disclosures”). IHCA …

Compliance behaviors of elderly patients with advanced heart failure.

Although compliance behaviors of heart failure (HF) patients have become the focus of increasing scrutiny in the last decade, the prevalence of noncompliance among elderly patients with HF is poorly understood. We conducted this study to describe and compare the compliance behaviors of elderly patients (≥65 years) and younger patients (<65 years) with HF on 6 prescribed activities: medical appointments, medications, diet, exercise, smoking cessation, and alcohol abstinence. Data from a sample of 140 older (50%) and younger (50%) HF patients matched for gender and disease severity were collected with the HF Compliance Questionnaire and analyzed via descriptive statistics, chi-square, paired t-tests, and Pearson correlations. We found that elderly patients were more compliant with diet (77% vs 65%, p = .001) and exercise (67% vs 55%, p = .021) than were their younger counterparts. There was no difference in the other health care behaviors. Of the 70 elderly patients, 51% reported some degree of difficulty complying with exercise while 37%, 24%, and 23% had difficulty following diet, keeping follow-up appointments, and taking medications, respectively. A smaller percentage of elders continued to smoke (9%) and drink alcohol (18%). Patients were asked why they had difficulty following their health care regimens; responses varied by prescribed activity. Lastly, we found inverse relationships between perceived difficulty following and compliance with all of the 6 behaviors measured (p < .001); as difficulty increased, compliance decreased. Strategies to help older patients minimize perceived difficulties associated with health care regimens may improve compliance and long-term morbidity and mortality from HF. Assumptions about older age being related to noncompliance appear invalid in patients with HF.

Correlates of anxiety, hostility, depression, and psychosocial adjustment in parents of NICU infants.

Purpose: The birth of a premature or critically ill infant can result in debilitating parental responses. This study identifies correlates of parental anxiety, hostility, depression, and psychosocial adjustment so that nurses can identify parents likely to need special attention or intervention. Design: An explanatory, correlational design was used. Sample: The study involved 469 parents (mothers = 299, 65 percent; mean age 29.1 ± 6.8 years) of infants hospitalized in five Level III NICUs. Main Outcome Variable: The main outcomes were those variables which correlated with the independent variables and included: parent status (mother or father), ethnicity, employment status, and education. Results: Parents experienced high levels of anxiety, hostility, and depression. Poorer family functioning, lower levels of social support, and lower perceived control were associated with higher levels of anxiety, hostility, and depression and with poorer adjustment. Parental status (mother or father), ethnicity, employment status, and education were significantly related to parental responses.

Impact of Anxiety and Perceived Control on In-Hospital Complications After Acute Myocardial Infarction

Objectives: We tested the hypothesis that perception of control moderates any relationship between anxiety and in-hospital complications (i.e., recurrent ischemia, reinfarction, sustained ventricular tachycardia or fibrillation, and cardiac death) in patients with acute myocardial infarction (AMI). Background: Anxiety is common among patients with AMI, but whether it is associated with poorer outcomes is controversial. Conflicting findings about the relationship of anxiety with cardiac morbidity and mortality may result from failure to consider the moderating effect of perceived control. Methods: This was a prospective examination of the association among anxiety, perceived control, and subsequent in-hospital complications among patients (N = 536) hospitalized for AMI. Results: Patients’ mean anxiety level was double that of the published mean norm. Patients with higher levels of perceived control had substantially lower anxiety (p = .001). A total of 145 (27%) patients experienced one or more in-hospital complications. Patients with higher levels of anxiety had significantly more episodes of ventricular tachycardia, ventricular fibrillation, and reinfarction and ischemia (p < .01 for all). In a multivariate hierarchical logistic regression model, left ventricular ejection fraction, history of myocardial infarction, anxiety score, and the interaction of anxiety and perceived control were significant predictors of complications. Conclusion: Anxiety during the in-hospital phase of AMI is associated with increased risk for in-hospital arrhythmic and ischemic complications that is independent of traditional sociodemographic and clinical risk factors. This relationship is moderated by level of perceived control such that the combination of high anxiety and low perceived control is associated with the highest risk of complications. AMI = acute myocardial infarction; CHD = coronary heart disease; BSI = Brief Symptom Inventory; CAS = Control Attitudes Scale.

Treatment-seeking delays in heart failure patients

BACKGROUND Patients having cardiac symptoms often delay for hours before seeking treatment. Delay time is usually defined as the amount of time between the patients first awareness of symptoms and arrival at the hospital. Excessive delays in seeking medical care for heart failure (HF) symptoms may influence patient outcomes. However, the treatment-seeking patterns of HF patients are not well understood. METHODS We obtained data through a retrospective chart audit to describe the treatment-seeking behaviors of 753 HF patients, at a Veterans Administration facility, and to identify predictors of delay in seeking medical care for HF symptoms. Using univariate and multivariate analyses, we assessed relationships among delay time, presenting symptoms, and patient characteristics. RESULTS The mean delay time was 2.93 +/- 0.68 days. The most common symptoms on admission were dyspnea (76%), edema (66%), fatigue (37%), and angina (25%). Variables negatively affecting delay time included presence of dyspnea and edema (odds ratio [OR], 2.10 and 1.82; confidence interval [CI], 1.38 to 3.19 and 1.17 to 2.82, respectively), care by a primary care physician (OR, 2.04; CI, 1.45 to 2.88), and higher New York Heart Association (NYHA) Class (OR, 1.96; CI, 1.47 to 2.61). Variables positively affecting delay time were the presence of chest pain (OR, 0.42; CI, 0.29 to 0.62) and a history of previous admission for HF (OR, 0.42; CI, 0.28 to 0.62). CONCLUSIONS Delays in seeking treatment for HF symptoms are significantly high. This study supports the need for interventions that will increase early symptom recognition and management on the part of patients and their families.

Comparison of prevalence of symptoms of depression, anxiety, and hostility in elderly patients with heart failure, myocardial infarction, and a coronary artery bypass graft.

OBJECTIVE This study sought to compare the prevalence of anxiety, depression, and hostility among 3 clinically diverse elderly cardiac patient cohorts and a reference group of healthy elders. METHODS This was a multicenter, comparative study. A total of 1167 individuals participated: 260 healthy elders, and 907 elderly cardiac patients who were at least 3 months past a hospitalization (478 heart-failure patients, 298 postmyocardial infarction patients, and 131 postcoronary artery bypass graft patients). Symptoms of anxiety, depression, and hostility were measured using the Multiple Affect Adjective Checklist. RESULTS The prevalence of anxiety, depression, and hostility was higher in patients in each of the cardiac patient groups than in the group of healthy elders. Almost three quarters of patients with heart failure reported experiencing symptoms of depression, and the heart-failure group manifested the greatest percentage of patients with depressive symptoms. CONCLUSIONS The high levels of emotional distress common in cardiac patients are not a function of aging, because healthy elders exhibit low levels of anxiety, depression, and hostility.

A Randomized Clinical Trial to Reduce Patient Prehospital Delay to Treatment in Acute Coronary Syndrome

Background—Delay from onset of acute coronary syndrome (ACS) symptoms to hospital admission continues to be prolonged. To date, community education campaigns on the topic have had disappointing results. Therefore, we conducted a clinical randomized trial to test whether an intervention tailored specifically for patients with ACS and delivered one-on-one would reduce prehospital delay time. Methods and Results—Participants (n=3522) with documented coronary heart disease were randomized to experimental (n=1777) or control (n=1745) groups. Experimental patients received education and counseling about ACS symptoms and actions required. Patients had a mean age of 67±11 years, and 68% were male. Over the 2 years of follow-up, 565 patients (16.0%) were admitted to an emergency department with ACS symptoms a total of 842 times. Neither median prehospital delay time (experimental, 2.20 versus control, 2.25 hours) nor emergency medical system use (experimental, 63.6% versus control, 66.9%) was different between groups, although experimental patients were more likely than control to call the emergency medical system if the symptoms occurred within the first 6 months following the intervention (P=0.036). Experimental patients were significantly more likely to take aspirin after symptom onset than control patients (experimental, 22.3% versus control, 10.1%, P=0.02). The intervention did not result in an increase in emergency department use (experimental, 14.6% versus control, 17.5%). Conclusions—The education and counseling intervention did not lead to reduced prehospital delay or increased ambulance use. Reducing the time from onset of ACS symptoms to arrival at the hospital continues to be a significant public health challenge. Clinical Trial Registration—clinicaltrials.gov. Identifier NCT00734760.

Gender differences in coronary artery disease.

Coronary artery disease in women is associated with higher morbidity and mortality than in men. The purpose of this article is to summarize recent literature concerning gender-based differences. Specific differences in pathophysiology, traditional and psychosocial risk factors, symptom presentation, treatments, and outcomes between women and men will be reviewed.

A nursing intervention to reduce prehospital delay in acute coronary syndrome: a randomized clinical trial.

Prehospital delay in patients experiencing symptoms of acute coronary syndrome (ACS) has proved to be a significant and intractable public health problem, with minimal change in delay time over the past 2 decades despite numerous community education programs designed to reduce delay. With each 30-minute increment of delay, 1-year mortality increases by 7.5%, thus reinforcing the importance of helping patients label symptoms correctly and take appropriate action steps to seek definitive treatment. We therefore are conducting a multicenter, international clinical trial in 3,500 patients with documented coronary heart disease to determine whether a brief education and counseling intervention delivered by a nurse can reduce prehospital delay in the face of symptoms of ACS. The main outcome being studied is time from ACS symptom onset to arrival at the emergency department. Secondary outcomes include use of the emergency medical system; aspirin use; and knowledge, attitudes, and beliefs about heart attack symptoms. Patients are being followed for 2 years from the time of enrollment. The purpose of this article is to describe the intervention and its theoretical framework, and to outline the design of this randomized controlled trial.