Sharon McKinley

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.

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.

International comparison of factors associated with delay in presentation for AMI treatment.

Background: Prehospital delay in response to acute myocardial infarction (AMI) symptoms is well documented in the US and Europe, but little is known about it in Asian countries where cardiovascular disease is increasing. Aims: We conducted an observational study of delay times and factors associated with hospital presentation times in 595 patients with AMI from the US, England, Japan and South Korea. Methods: Patients were interviewed about responses to symptoms within 72 h of hospital admission and the medical records were reviewed. Results: The proportions of patients with delay times of 1 h or less were: US—23%, Korea—18%, England—15% and Japan—8%. In the US and England when others present at symptom onset called an ambulance patients presented two to three times sooner. Independent predictors of presentation within an hour of symptom onset were attribution of symptoms to the heart and not waiting for symptoms to go away. Conclusion: Similar education about the need to seek treatment early in response to AMI symptoms may be applicable in Western and Eastern industrialised populations.

Patient Recognition of and Response to Symptoms of TIA or Stroke

Background and Purpose: Campaigns within Australia and internationally have sought to increase awareness of the emergent nature of stroke. For these initiatives to be effective it is important to gather information about delay in seeking treatment and the reasons given for the delay by people with stroke. The purpose of this study was to examine delay in seeking treatment in people with an evolving stroke or TIA and identify clinical, behavioral and demographic factors that contributed to the delay. Subjects and Methods: During a 1-year period 150 participants were given the Response to Stroke Symptoms Questionnaire. The six domains included in the questionnaire were: (1) context in which the stroke occurred; (2) antecedents to symptoms; (3) affective response to symptoms; (4) behavioral response to symptoms; (5) cognitive response to symptoms; (6) the response of others to patient symptoms. Results: The median delay time from symptom onset to admission to hospital was 4.5 h. While 41% of participants delayed less than 3 h, more than 45% delayed greater than 6 h. Independent predictors of delay time included mode of arrival at hospital with those taking an ambulance having a median delay time of 2.7 h vs. 15.4 h for those arriving by private car (p = 0.04). Gender also predicted delay with women delaying longer (p = 0.001). The first response of others was also an independent predictor of delay time (p = 0.003) with those who called the emergency services number or took the patient to hospital resulting in the shortest patient delays. Finally, if the patient appraised their symptoms as serious they had a shorter delay time (p = 0.02). Conclusions: The message about the emergent nature of stroke may be helping to improve delay times. However, there are still many people who delay greater than 3 h after symptom onset. It is important to direct education programs to those with known risk factors for stroke and their families, who often make the decision to call an ambulance.

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.

Persistent Comorbid Symptoms of Depression and Anxiety Predict Mortality in Heart Disease

BACKGROUND Incident anxiety and depression are associated separately with cardiac events and mortality in patients after acute coronary syndromes, but the influence of persistent comorbid depression and anxiety on mortality remains unknown. The purpose of this study was to determine the prevalence of comorbid persistent depressive and anxious symptoms in individuals with ischemic heart disease and to evaluate effects on mortality. METHODS Prospective, longitudinal cohort design in the context of a randomized trial to decrease patient delay in seeking treatment for ischemic heart symptoms (PROMOTION trial) was used, with twelve-month follow-up of 2325 individuals with stable ischemic heart disease. Participants were assessed on enrollment and at 3 months using the Multiple Adjective Affect Checklist and the Brief Symptom Inventory for depressive and anxious symptoms, respectively. RESULTS At 3 months, 608 individuals (61.7%) reported persistent symptoms of depression, anxiety, or both. Three hundred seventy-nine (42.5%) and 1056 (45.4%) had persistent anxious and depressive symptoms, respectively. Those with persistent, comorbid symptoms had higher mortality compared to others (p=.029). The combined presence of anxious and depressive symptoms contributed significantly to mortality when compared to symptom-free participants (OR 2.35, 95% CI 1.23-4.47, p=.010). The presence of persistent depressive symptoms only and persistent anxious symptoms only were not associated with death, when other demographic and clinical variables were considered. CONCLUSIONS Persistent symptoms of anxiety and depression increased substantially the risk of death in patients with ischemic heart disease. Future research into shared and unique pathways and treatments is needed.

The effect of a short one-on-one nursing intervention on knowledge, attitudes and beliefs related to response to acute coronary syndrome in people with coronary heart disease: A randomized controlled trial

BACKGROUND Coronary heart disease (CHD) and acute coronary syndrome (ACS) remain significant public health problems. The effect of ACS on mortality and morbidity is largely dependent on the time from symptom onset to the time of reperfusion, but patient delay in presenting for treatment is the main reason timely reperfusion is not received. OBJECTIVES We tested the effect of an education and counseling intervention on knowledge, attitudes and beliefs about ACS symptoms and the appropriate response to symptoms, and identified patient characteristics associated with changes in knowledge, attitudes and beliefs over time. METHODS We conducted a two-group randomized controlled trial in 3522 people with CHD. The intervention group received a 40 min, one-on-one education and counseling session. The control group received usual care. Knowledge, attitudes and beliefs were measured at baseline, 3 and 12 months using the ACS Response Index and analyzed with repeated measures analysis of variance. RESULTS Knowledge, attitudes and beliefs scores increased significantly from baseline in the intervention group compared to the control group at 3 months, and these differences were sustained at 12 months (p=.0005 for all). Higher perceived control over cardiac illness was associated with more positive attitudes (p<.0005) and higher state anxiety was associated with lower levels of knowledge (p<.05), attitudes (p<.05) and beliefs (p<.0005). CONCLUSION A relatively short education and counseling intervention increased knowledge, attitudes and beliefs about ACS and response to ACS symptoms in individuals with CHD. Higher perceived control over cardiac illness was associated with more positive attitudes and higher state anxiety was associated with lower levels of knowledge, attitudes and beliefs about responding to the health threat of possible ACS.

The Control Attitudes Scale-Revised: psychometric evaluation in three groups of patients with cardiac illness.

Background: Perceived control is a construct with important theoretical and clinical implications for healthcare providers, yet practical application of the construct in research and clinical practice awaits development of an easily administered instrument to measure perceived control with evidence of reliability and validity. Objective: To test the psychometric properties of the Control Attitudes Scale-Revised (CAS-R) using a sample of 3,396 individuals with coronary heart disease, 513 patients with acute myocardial infarction, and 146 patients with heart failure. Methods: Analyses were done separately in each patient group. Reliability was assessed using Cronbachs alpha to determine internal consistency, and item homogeneity was assessed using item-total and interitem correlations. Validity was examined using principal component analysis and testing hypotheses about known associations. Results: Cronbachs alpha values for the CAS-R in patients with coronary heart disease, acute myocardial infarction, and heart failure were all greater than .70. Item-total and interitem correlation coefficients for all items were acceptable in the groups. In factor analyses, the same single factor was extracted in all groups, and all items were loaded moderately or strongly to the factor in each group. As hypothesized in the final construct validity test, in all groups, patients with higher levels of perceived control had less depression and less anxiety compared with those of patients who had lower levels of perceived control. Conclusion: This study provides evidence of the reliability and validity of the 8-item CAS-R as a measure of perceived control in patients with cardiac illness and provides important insight into a key patient construct.

Critical care nursing practice regarding patient anxiety assessment and management

Anxiety is common in critically ill patients and can adversely affect recovery if not properly assessed and treated. The objectives of this study were to: (1) identify the clinical indicators that critical care nurses consider to be the defining attributes of anxiety in critically ill patients; and (2) delineate the interventions that critical care nurses use to alleviate anxiety in their patients. A total of 2500 nurses who worked in adult critical care areas were randomly selected from the membership of the American Association of Critical Care Nurses. Nurses selected were mailed a survey designed to determine what they considered to be the important attributes of anxiety in their patients and what interventions they commonly used to manage anxiety. The 593 nurses (31.6% response rate) who responded identified 70 individual anxiety indicators and 61 anxiety management strategies that were categorized into four and three major categories, respectively. The four major anxiety assessment categories were: (1) physical/physiological; (2) behavioral; (3) psychological/cognitive; and (4) social. The three major anxiety management strategies were: (1) care techniques; (2) improving knowledge and communication; and (3) support. Critical care nurses reported numerous and distinctive anxiety indicators and management strategies. Further research is needed to examine exactly how appropriate and effective these assessment indicators and management strategies are.

Cardiovascular risk in early bereavement: A literature review and proposed mechanisms

OBJECTIVES The purpose of this review was to examine the evidence of cardiovascular risk in early bereavement to identify potential risk factors and possible mechanisms for risk that may inform future research directions. DESIGN A comprehensive search of electronic databases PubMed Medline, CINAHL and PsycINFO, bereavement related textbooks and reviewed reference lists was undertaken on literature related to evidence of increased risk in bereavement. No limits were set on the searches in terms of date or publication type, but only English language articles were selected. FINDINGS Bereavement represents a time of heightened cardiovascular risk for the surviving spouse. The immediate weeks following bereavement represent the highest risk period with both men and women across all ages. Risk is evident irrespective of the nature of death, expected or unexpected, although higher level of social support at the time of death may be protective. Evidence would suggest that for many, bereavement results in a time of increased psychological stress and potential for altered behavioural health risk factors that in the presence of altered physiological state, may serve as a potential trigger of cardiovascular events, especially in those most at risk. CONCLUSION The findings from this review provide insight into the impact of early bereavement on health and the recognition that bereavement is associated with increased cardiac risk. This recognition should provide an impetus for individuals to act on cardiac symptoms by seeking medical advice and for health care providers to monitor such individuals more closely.