Susan E. Abbey

Cardiac rehabilitation II: referral and participation

Cardiovascular disease (CVD) is the leading cause of death and disability for women and men. Substantial health risks continue following ischemic coronary events (ICEs), but secondary prevention efforts, including cardiac rehabilitation (CR), have beneficial effects on both early and late mortality and morbidity. This prospective study examined the relationship among psychosocial factors and CR referral and participation patterns in 906 (586 men, 320 women) patients from the coronary intensive care unit (CICU) over the course of six months. Only 30% of participants were referred to CR programs, with significantly fewer women being referred. A logistic regression analysis was used to determine whether depression, anxiety, self-efficacy, or social support predicted CR participation six months following an ICE, while controlling for sociodemographic factors. Results show that higher family income, greater anxiety symptomatology, and higher self-efficacy were significantly predictive of CR participation at six months. Implications for womens recovery from an ICE are discussed.

Structure of lifestyle disruptions in chronic disease: a confirmatory factor analysis of the Illness Intrusiveness Ratings Scale.

Background.The Illness Intrusiveness Ratings Scale (IIRS) measures the extent to which disease or its treatment or both interfere with activities in important life domains. Before comparing IIRS scores within or across groups it is crucial to determine whether a common underlying factor structure exists across patient populations. Objective.To investigate the factor structure underlying the IIRS and evaluate its stability across diagnoses. Methods.IIRS responses from 5,671 respondents were pooled from 15 separate studies concerning quality of life in eight patient groups: rheumatoid arthritis; osteoarthritis; systemic lupus erythematosus; multiple sclerosis; end-stage renal disease (maintenance dialysis); renal transplantation; heart, liver, and lung transplantation; and insomnia. Data were gathered by different methods (eg, interview, self-administered, mail survey) and in diverse contexts (eg, individual vs. group). Results.Exploratory maximum-likelihood factor analysis identified three underlying factors in a randomly selected subset of respondents (n = 400), corresponding to “Relationships and Personal Development,” “Intimacy,” and “Instrumental” life domains. Confirmatory factor analysis corroborated the stability of this structure in an independent subsample (n = 2100). Complementary goodness-of-fit indices confirmed the consistency of the three-factor solution, corroborating that IIRS scores are uniquely defined across patient populations. Coefficient alpha was high for total and subscale scores. Conclusions.IIRS scores can be compared meaningfully within and across patient groups. Both total and subscale scores can be used depending on research objectives.

Preoperative use of statins is associated with reduced early delirium rates after cardiac surgery.

Background:Delirium is an acute deterioration of brain function characterized by fluctuating consciousness and an inability to maintain attention. Use of statins has been shown to decrease morbidity and mortality after major surgical procedures. The objective of this study was to determine an association between preoperative administration of statins and postoperative delirium in a large prospective cohort of patients undergoing cardiac surgery with cardiopulmonary bypass. Methods:After Institutional Review Board approval, data were prospectively collected on consecutive patients undergoing cardiac surgery with cardiopulmonary bypass from April 2005 to June 2006 in an academic hospital. All patients were screened for delirium during their hospitalization using the Confusion Assessment Method in the intensive care unit. Multivariable logistic regression analysis was used to identify independent perioperative predictors of delirium after cardiac surgery. Statins were tested for a potential protective effect. Results:Of the 1,059 patients analyzed, 122 patients (11.5%) had delirium at any time during their cardiovascular intensive care unit stay. Administration of statins had a protective effect, reducing the odds of delirium by 46%. Independent predictors of postoperative delirium included older age, preoperative depression, preoperative renal dysfunction, complex cardiac surgery, perioperative intraaortic balloon pump support, and massive blood transfusion. The model was reliable (Hosmer-Lemeshow test, P = 0.3) and discriminative (area under receiver operating characteristic curve = 0.77). Conclusions:Preoperative administration of statins is associated with the reduced risk of postoperative delirium after cardiac surgery with cardiopulmonary bypass.

Prospective Examination of Anxiety Persistence and Its Relationship to Cardiac Symptoms and Recurrent Cardiac Events

Background: The current study builds on previous research demonstrating a link between anxiety and inhospital recurrent ischemic and arrhythmic events, by examining the effects of persistent anxiety on recurrent events 1 year later. Methods: 913 patients with unstable angina (UA) and myocardial infarction (MI) from 12 coronary care units were recruited, and follow-up data were collected at 6 and 12 months after the event. Measures included cardiac symptomatology, healthcare utilization, the anxiety subscale of the Primary Care Evaluation of Mental Disorders , the phobic anxiety subscale of the Middlesex Hospital Questionnaire, and the Beck Depression Inventory. Results: Over one third of participants with UA and MI experienced elevated anxiety at the time of the ischemic event, and these symptoms persisted for 1 year in 50% of anxious participants. Although participants with anxiety reported more atypical cardiac symptomatology, the prevalence of typical cardiac symptoms such as chest pain did not differ based on anxiety. After controlling for the severity of the coronary event, family income, sex, diabetes, and smoking, the following variables were significantly predictive of self-reported recurrent cardiac events at 6 months or 1 year: older age, family history of cardiovascular disease, greater depressive symptomatology at baseline, and anxiety at 6 months. Only 38% of anxious patients were asked about such symptoms, indicating underutilization of effective psychotherapeutic treatment. Conclusions: Over and above the effects of depressive symptomatology (among other confounding variables), nonphobic anxiety appears to have a negative effect on self-reported outcome following an ischemic coronary event. Anxiety symptomatology is underrecognized and undertreated, and examination of effects of treatment on secondary prevention must be pursued.

Longitudinal Course of Depressive Symptomatology After a Cardiac Event: Effects of Gender and Cardiac Rehabilitation

Objective: Recent research has linked depression to cardiac mortality, and shown a high burden of persistent depressive symptomatology among cardiac patients. The objective of this study was to longitudinally examine the prevalence and course of depressive symptomatology among women and men for 1 year after a cardiac event, and the effect of cardiac rehabilitation (CR) on this trajectory. Methods: Nine hundred thirteen unstable angina (UA) and myocardial infarction patients from 12 coronary care units were recruited, and follow-up data were collected at 6 and 12 months. Measures included CR participation, medication usage, and the Beck Depression Inventory (BDI). The longitudinal analysis was conducted using SAS PROC MIXED. Results: At baseline there were 277 (31.3%) participants with elevated depressive symptomatology (BDI ≥ 10), 131 (25.2%) at 6 months, and 107 (21.7%) at 1 year. Overall, approximately 5% were taking an antidepressant medication, and 20% attended CR over their year of recovery. Participants with greater depressive symptomatology participated in significantly fewer CR exercise sessions (r = −0.19, p = .02), and minimal psychosocial interventions were offered. The longitudinal analysis revealed that all participants experienced reduced depressive symptomatology over their year of recovery (p = .04), and younger, UA participants with lower family income fared worst (ps < 0.001). CR did not have an effect on depressive symptomatology over time, but women who attended CR were significantly more depressed than men (p = .01). Conclusion: Depressed cardiac patients are undertreated and their symptomatology persists for up to 6 months. CR programs require greater resources to ensure that depressed participants adhere to exercise regimens, and are screened and treated for their elevated symptomatology. CR = cardiac rehabilitation; UA = unstable angina; MI = myocardial infarction; ACS = acute coronary syndromes; CCU = coronary care unit; CAD = Canadian dollars; USD = U.S. dollars; BDI = Beck Depression Inventory.

Cardiac rehabilitation I: review of psychosocial factors

Cardiovascular disease (CVD) is the leading cause of death and disability for women and men. There are gender differences in recovery from coronary events, which may be due physiological, sociodemographic, or psychosocial factors. Cardiac rehabilitation programs have beneficial effects on coronary recovery. The following presents a review of the literature from MedLine (1997-2001) and PsychInfo (1984-2001) on gender differences in participation in cardiac rehabilitation programs, with a focus on depression, anxiety, self-efficacy and social support. A critical analysis of gaps in the literature as well as areas for future research are presented.

Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience.

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end‐stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow‐up of 12 months (range 12–96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 ± 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long‐term follow‐up may contribute to favorable donor outcomes.

Psychological factors and depressive symptoms in ischemic heart disease.

The aim of this study was to determine whether learned helplessness, cognitive distortions, self-efficacy, and dispositional optimism assessed at Time 1 (T1; questionnaires mailed at 1 month postdischarge) would predict depressive symptoms at Time 2 (T2; questionnaires mailed at 1-year follow-up) in a sample of 86 patients hospitalized with ischemic heart disease. Multiple regression results indicated that optimism and cognitive distortions at T1 were significantly associated with T1 depressive symptoms after controlling for confounding variables. When the T1 psychological factors were analyzed with T2 depressive symptoms, only optimism continued to predict depressive symptoms after controlling for confounds and T1 depressive symptoms. The global expectancies that optimism assessed appeared to be more stable over time than the statelike beliefs of cognitive distortions and may have accounted for why optimism predicted T2 depressive symptoms.

Adult Right-Lobe Living Liver Donors: Quality of Life, Attitudes and Predictors of Donor Outcomes

To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health‐related quality of life (HRQOL) must be identified. This cross‐sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF‐36) and measures of the pre‐ and postdonation process. Donor scores on the SF‐36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow‐up. Risk factors identified in this study should be prospectively evaluated in future research.

Managing Depression During Hepatitis C Treatment

Objective: The prevalence of hepatitis C virus (HCV) infection in Canada is estimated to be 1% and expected to increase during the next decade. Mental illness, particularly depression, is common among HCV-infected patients and remains an obstacle to interferon-alpha (IFN-α) treatment. We summarize the risk factors for interferon-α–induced major depressive disorder (IFN-α–MDD) in HCV patients and the evidence for antidepressant prophylaxis and symptomatic antidepressant treatment of depression. Methods: We searched MEDLINE, EMBASE, and CINAHL for randomized controlled or quasi-experimental trials evaluating antidepressant prophylactic and symptomatic treatment approaches for depression emerging during IFN-α treatment. Manual searches of references listed in review articles, case series, and anecdotal reports supplemented our literature search. Results: A total of 9 trials involving prophylactic and symptomatic treatment approaches for IFN-α–MDD are summarized in our review. Antidepressant pretreatment is beneficial for patients with elevated baseline depressive symptoms and a preexisting history of IFN-α–MDD. Although limited evidence exists for several antidepressant agents, much of the evidence suggests that selective serotonin reuptake inhibitors (SSRIs) are safe and efficacious in treating depressive symptoms secondary to IFN-α therapy. Conclusion: Both antidepressant pretreatment and symptomatic treatment are viable strategies for treating IFN-α–MDD. Improved treatment outcomes and early identification of depression during HCV treatment can be achieved using an integrated medical and mental health treatment approach.