Marian U.C. Worcester

Attendance at cardiac rehabilitation is associated with lower all-cause mortality after 14 years of follow-up

Objective To investigate whether attendance at cardiac rehabilitation (CR) independently predicts all-cause mortality over 14 years and whether there is a dose–response relationship between the proportion of CR sessions attended and long-term mortality. Design Retrospective cohort study. Setting CR programmes in Victoria, Australia Patients The sample comprised 544 men and women eligible for CR following myocardial infarction, coronary artery bypass surgery or percutaneous interventions. Participants were tracked 4 months after hospital discharge to ascertain CR attendance status. Main outcome measures All-cause mortality at 14 years ascertained through linkage to the Australian National Death Index. Results In total, 281 (52%) men and women attended at least one CR session. There were few significant differences between non-attenders and attenders. After adjustment for age, sex, diagnosis, employment, diabetes and family history, the mortality risk for non-attenders was 58% greater than for attenders (HR=1.58, 95% CI 1.16 to 2.15). Participants who attended <25% of sessions had a mortality risk more than twice that of participants attending ≥75% of sessions (OR=2.57, 95% CI 1.04 to 6.38). This association was attenuated after adjusting for current smoking (OR=2.06, 95% CI 0.80 to 5.29). Conclusions This study provides further evidence for the long-term benefits of CR in a contemporary, heterogeneous population. While a dose–response relationship may exist between the number of sessions attended and long-term mortality, this relationship does not occur independently of smoking differences. CR practitioners should encourage smokers to attend CR and provide support for smoking cessation.

Health related quality of life trajectories and predictors following coronary artery bypass surgery

BackgroundMany studies have demonstrated that health related quality of life (HRQoL) improves, on average, after coronary artery bypass graft surgery (CABGS). However, this average improvement may not be realized for all patients, and it is possible that there are two or more distinctive groups with different, possibly non-linear, trajectories of change over time. Furthermore, little is known about the predictors that are associated with these possible HRQoL trajectories after CABGS.Methods182 patients listed for elective CABGS at The Royal Melbourne Hospital completed a postal battery of questionnaires which included the Short-Form-36 (SF-36), Profile of Mood States (POMS) and the Everyday Functioning Questionnaire (EFQ). These data were collected on average a month before surgery, and at two months and six months after surgery. Socio-demographic and medical characteristics prior to surgery, as well as surgical and post-surgical complications and symptoms were also assessed. Growth curve and growth mixture modelling were used to identify trajectories of HRQoL.ResultsFor both the physical component summary scale (PCS) and the mental component summary scale (MCS) of the SF-36, two groups of patients with distinct trajectories of HRQoL following surgery could be identified (improvers and non-improvers). A series of logistic regression analyses identified different predictors of group membership for PCS and MCS trajectories. For the PCS the most significant predictors of non-improver membership were lower scores on POMS vigor-activity and higher New York Heart Association dyspnoea class; for the MCS the most significant predictors of non-improver membership were higher scores on POMS depression-dejection and manual occupation.ConclusionIt is incorrect to assume that HRQoL will improve in a linear fashion for all patients following CABGS. Nor was there support for a single response trajectory. It is important to identify characteristics of each patient, and those post-operative symptoms that could be possible targets for intervention to improve HRQoL outcomes.

Resumption of Work After Acute Coronary Syndrome or Coronary Artery Bypass Graft Surgery

BACKGROUND Return to work is an important indicator of recovery after acute cardiac events. This study aimed to determine rates of work resumption and identify predictors of non-return to work and delayed resumption of work. METHODS 401 currently employed patients consecutively admitted after acute coronary syndrome or to undergo coronary artery bypass graft surgery were recruited. Patient characteristics, perceptions and occupational outcomes were investigated via interviews and self-report questionnaires. RESULTS Twenty-three patients were lost to follow-up. Of the 378 completers, 343 (90.7%) patients resumed work, while 35 (9.3%) did not. By four months, 309 (91.1%) patients had returned to work. At 12 months, 302 (79.9%) of the 378 patients were employed, 32 (8.5%) unemployed and 20 (5.3%) retired. The employment status of 24 (6.3%) patients was unknown. Non-return to work was significantly more likely if patients were not intending to return to work or were uncertain, had a negative perception of health, had a comorbidity other than diabetes and reported financial stress. Significant predictors of delayed return to work were cardiac rehabilitation attendance, longer hospital stay, past angina, having a manual job, physically active work, job dissatisfaction, no confidante and depression. CONCLUSIONS Patients at risk of poor occupational outcomes can be identified early. Strategies to improve vocational rehabilitation require further investigation.

Are poor health behaviours in anxious and depressed cardiac patients explained by sociodemographic factors

Introduction: While there is evidence of poor health behaviours in anxious and depressed cardiac patients, it is possible that sociodemographic factors explain these associations. Few previous studies have adequately controlled for confounders. The present study investigated health behaviours in anxious and depressed cardiac patients, while accounting for sociodemographic confounders. Method: A consecutive sample of 275 patients admitted to hospital after acute myocardial infarction (32%) or for coronary bypass surgery (40%) or percutaneous coronary intervention (28%) was interviewed six weeks after hospital discharge. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Smoking, physical activity, alcohol intake and dietary fat intake were assessed by self-report. Backward stepwise logistic regression was used to identify the factors independently associated with anxiety and depression. Results: In total, 41 patients (15.2%) were ‘depressed’ (HADS-D ≥8) while 68 (25.2%) were ‘anxious’ (HADS-A ≥8). Depressed patients reported higher rates of smoking (χ2 = 4.47, p = 0.034), lower physical activity (F = 8.63, p < 0.004) and higher dietary fat intake (F = 7.22, p = 0.008) than non-depressed patients. Anxious patients reported higher smoking rates (χ2 = 5.70, p = 0.024) and dietary fat intake (F = 7.71, p = 0.006) than non-anxious patients. In multivariate analyses, an association with depression was retained for both diet and physical activity, and an association with anxiety was retained for diet. Low social support and younger age were significant confounders with depression and anxiety respectively. Conclusions: While the high smoking rates evidenced in anxious and depressed patients were explained by sociodemographic factors, their poor diet and low physical activity (depressed patients only) were independent of these factors. Given the impact of lifestyle modification on survival after a cardiac event, anxious and depressed patients should be a priority for cardiac rehabilitation and other secondary prevention programmes.

Identifying illness perception schemata and their association with depression and quality of life in cardiac patients

The purpose of this paper is to identify groups of cardiac patients who share similar perceptions about their illness and to examine the relationships between these schemata and psychosocial outcomes such as quality of life and depression. A total of 190 cardiac patients with diagnoses of myocardial infarction, stable angina pectoris or chronic heart failure, completed a battery of psychosocial questionnaires within four weeks of their admission to hospital. These included the Brief Illness Perceptions Questionnaire (BIPQ), Beck Depression Inventory II (BDI II) and The MacNew Health-related Quality of Life instrument (MacNew). BIPQ items were subjected to latent class analysis (LCA) and the resulting groups were compared according to their BDI II and MacNew scores. LCA identified a five-class model of illness perception which comprised the following: (1) Consequence focused and mild emotional impact, n = 55, 29%; (2) Low illness perceptions and low emotional impact, n = 45, 24%; (3) Control focused and mild emotional impact, n = 10, 5%; (4) Consequence focused and high emotional impact, n = 60, 32%; and (5) Consequence focused and severe emotional impact, n = 20, 10%. Gender and diagnosis did not appear to reflect class membership except that class 2 had a significantly higher proportion of AMI patients than did class 5. There were numerous significant differences between classes in regards to depression and health-related quality of life. Notably, classes 4 and 5 are distinguished by relatively high BDI II scores and low MacNew scores. Identifying classes of cardiac patients based on their illness perception schemata, in hospital or shortly afterwards, may identify those at risk of developing depressive symptoms and poor quality of life.

Red flags for persistent or worsening anxiety and depression after an acute cardiac event: a 6-month longitudinal study in regional and rural Australia

Background While early symptoms of anxiety and depression resolve for many patients soon after an acute cardiac event, the persistence or worsening of symptoms indicates increased mortality risk. It is therefore important to identify the predictors, or red flags, of persistent or worsening anxiety and depression symptoms. Most previous research has focussed on metropolitan patients, hence the need for studies of regional and rural dwellers. Method In this study, 160 cardiac patients consecutively admitted to two hospitals in regional Victoria, Australia, were interviewed in hospital and 2 and 6 months after discharge. Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale. Growth mixture modelling was used to identify the trajectories of anxiety and depression over the 6 months after the acute event, and post-hoc tests identified predictors of persistent or worsening symptoms. Results For both anxiety and depression, three common symptom trajectories were identified. Inhospital anxiety symptoms tended to persist over time, whereas inhospital depression symptoms resolved for some patients and worsened for others. A mental health history, younger age, smoking, financial stress, poor self-rated health, and social isolation were red flags for persistent anxiety and worsening depression. Additionally, diabetes, and other comorbidities were red flags for persistent anxiety. Conclusions The results highlight several potential red flags for increased risk of persistent anxiety or worsening depressive symptoms after a cardiac event, including demographic, psychosocial, and behavioural indicators. These red flags could assist with identification of at-risk patients on admission to or discharge from hospital, thereby enabling targeting of interventions.

An integrated secondary prevention group programme reduces depression in cardiac patients

Objective Depression is common following an acute cardiac event and can occur at a time when behaviour change is strongly recommended to reduce the risk of further cardiovascular events. The ‘Beating Heart Problems’ programme was designed to support cardiac patients in behaviour change and mood management. Methods The programme was based on cognitive behaviour therapy and motivational interviewing. A randomized controlled trial (RCT) comparing the 8-week group programme with usual care was undertaken between 2007 and 2010. All patients attended a hospital-based clinic for assessment of physiological risk factors at baseline (6 weeks after their acute event), and at 4- and 12-month follow up. Psychological and behavioural indicators were assessed by self-report questionnaires. Of the 275 patients enrolled into the RCT, 42 (15%) had Beck Depression Inventory-II scores >13 at baseline. Treatment and control group comparisons were undertaken for this subgroup, using growth curve modelling and testing for group differences over time in psychological, physiological, health behaviour, and self-efficacy measures. Results Significantly greater improvements (p < 0.01) in depression symptoms and self-rated health were reported for the intervention group, as well as significantly larger gains in confidence in managing depression (p < 0.05) and anger (p < 0.01). Trends (0.05 < p < 0.10) for larger treatment group improvements were also seen for anxiety symptoms and confidence in managing anxiety. Conclusion A group secondary-prevention programme that integrates behavioural and mood management strategies leads to decreased depression, increased confidence, and improved health perceptions in depressed cardiac patients.

Changes in Mood States After Coronary Artery Bypass Graft Surgery

Few studies have investigated the change in mood states, such as anger, fatigue and confusion, after coronary artery bypass graft surgery (CABGS). The aim of this study was to describe the progression of these mood states over time and to determine the factors associated with these trajectories. The Profile of Mood States (POMS) was administered to 182 CABGS patients prior to surgery and at two and six months post-operatively. Socio-demographic and medical data were collected before surgery. Growth curve modelling was used to describe the POMS subscale trajectories. Four POMS subscales (tension–anxiety, fatigue–inertia, confusion–bewilderment, and vigour–activity) showed rapid improvement over the first two months after CABGS followed by a lesser improvement. There was no significant change over time for the depression–dejection and anger–hostility subscales. Being younger, male, having a manual occupation, and smoking were factors associated with poorer pre-operative mood states. Those at risk of persistent mood disturbance after CABGS were younger, unpartnered, female and those with diabetes. These patients can be identified prior to hospital admission.

Predictors of cognitive function in candidates for coronary artery bypass graft surgery

Candidates for coronary artery bypass graft surgery have been found to exhibit reduced cognitive function prior to surgery. However, little is known regarding the factors that are associated with pre-bypass cognitive function. A battery of neuropsychological tests was administered to a group of patients listed for bypass surgery (n = 109). Medical, sociodemographic and emotional predictors of cognitive function were investigated using structural equation modeling. Medical factors, namely history of hypertension and low ejection fraction, significantly predicted reduced cognitive function, as did several sociodemographic characteristics, namely older age, less education, non-English speaking background, manual occupation, and male gender. One emotional variable, confusion and bewilderment, was also a significant predictor whereas anxiety and depression were not. When significant predictors from the three sets of variables were included in a combined model, three of the five sociodemographic characteristics, namely age, non-English speaking background and occupation, and the two medical factors remained significant. Apart from sociodemographic characteristics, medical factors such as a history of hypertension and low ejection fraction significantly predicted reduced cognitive function in bypass candidates prior to surgery.

Cardiac rehabilitation mortality trends: how far from a true picture are we?

To the Editor , Thank you for the opportunity to respond to this editorial,1 which questions our findings of a greater mortality risk of 58% for cardiac rehabilitation (CR) non-attenders compared to attenders.1 ,2 While this effect size is larger than some reports, benefits of this magnitude have been seen by other studies with patient samples comparable to ours. These recent studies found similar effect sizes of 45–59%.3–5 The authors also comment that ‘it may be that Melbourne CR programmes are really that good’.1 A 1996 survey of Victorian CR programmes conducted by the …