Behavioral interventions for coronary heart disease patients

Abstract Introduction There is a strong clinical need to provide effective stress reduction programs for patients with an acute coronary syndrome. Such programs for men have been implemented and their cardiovascular health benefit documented. For women such programs are scarce. In this report, The feasibility of a cognitive method that was recently demonstrated to prolong lives of women is tested. A setting with gender segregated groups was applied. Method The principles of a behavioural health educational program originally designed to attenuate the stress of patients with coronary prone behaviours were used as a basis for the intervention method. For the groups of female patients this method was tailored according to female stressors and for the groups of men according to male stressors. The same core stress reduction program was used for women and men, but the contents of discussions and responses to the pre planned program varied. These were continuously monitored throughout the fifteen sessions. Implementation group: Thirty consecutive patients, eleven women and nineteen men, hospitalized for an acute coronary syndrome were included in this intervention. All expressed their need to learn how to cope with stress in daily life and were highly motivated. Five groups, three groups of men and two groups of women were formed. Psychological assessments were made immediately before and after completion of the program. Results No gender differences in the pre planned programs were found, but discussion styles varied between the women and men, Women were more open and more personal. Family issues were more frequent than job issues, although all women were employed outside their homes. Men talked about concrete and practical things, mostly about their jobs, and not directly about their feelings. Daily stresses of life decreased significantly for both men and women, but more so for women. Depressive thoughts were low at baseline, and there was no change over time. In contrast, anxiety scores were high at baseline and decreased significantly, but more so for women than for men. Conclusion Women are likely to benefit from women's groups. Men may prefer to have one or two women in the group, but women fare better in gender segregated groups.</p

Relation of morning serum cortisol to prothrombotic activity in women with stable coronary artery disease

Background: Increased circulating cortisol levels have been associated with severity of atherosclerosis. Low-grade systemic thrombogenicity plays a major role in the initiation and progression of coronary disease. We hypothesized a direct relationship between cortisol and hemostasis factors related to a prothrombotic state in coronary artery disease. Methods: We measured morning serum cortisol and activated clotting factor VII, fibrinogen, von Willebrand factor antigen, and plasminogen activator inhibitor-1 activity in 285 women (56±7years) between 3 and 6months after an acute coronary event. To test whether the relationship between cortisol and hemostasis factors would be independent, statistical adjustment was made for demographic, biomedical, life style, and psychosocial variables. Results: Higher serum cortisol levels predicted higher fibrinogen (β=.17, P=.001) and higher von Willebrand factor (β=.16, P=.008), all independently of covariates, including C-reactive protein, which was also an independent predictor of fibrinogen (β=.20, P=.001) and von Willebrand factor (β=.16, P=.004). Higher levels of vital exhaustion were associated with higher levels of activated clotting factor VII independently of covariates and depression (β=.18, P=.045). Cortisol showed crude correlations with vital exhaustion (r=.14, P=.022) and with depression (r=.13, P=.043) but did not mediate the relationship between psychosocial variables and hemostatic factors. Conclusions: Morning serum cortisol showed a modest but independent association with prothrombotic activity in women with coronary artery disease suggesting that increased cortisol levels might contribute to atherosclerosis via eliciting a hypercoagulable stat

The measurement of social support in population surveys

There is an increasing interest to include measures of social support in population surveys of chronic disease risk. The choice among a variety of measurement instruments, however, is difficult. We reviewed social support instruments, which were potentially applicable in population studies. Their conceptual framework, their reported predictive capacity and their psychometric properties were compiled and systematically compared. The convenience, clarity and applicability of the social support instruments were tested in a group of health care employees. Two distinct groups of instruments were identified, those describing quantitative aspects of social network and social interaction and those describing functions and adequacy of social support. The former instruments were more easily applicable, questions were more easily and quickly understood and answered. Furthermore, these instruments had been found to predict physical illness in prospective studies. Their psychometric properties, however, were unknown. Qualitative instruments, on the other hand, were found to include questions, not universally applicable to a general population. These instruments were mostly carefully tested for psychometric properties, but their illness predictive capacity was found to be less well examined. Thus, instruments which satisfied all the desirable requirements could not be identified.social network social support measurements psychometric properties psychosocial profile population surveys

Autonomic Function and Prothrombotic Activity in Women after an Acute Coronary Event

BACKGROUND: The link between decreased heart rate variability (HRV) and atherosclerosis progression is elusive. We hypothesized that reduced HRV relates to increased levels of prothrombotic factors previously shown to predict coronary risk. METHODS: We studied 257 women (aged 56 +/- 7 years) between 3 and 6 months after an acute coronary event and obtained very low frequency (VLF), low frequency (LF), and high frequency (HF) power, and LF/HF ratio from 24-hour ambulatory ECG recordings. Plasma levels of activated clotting factor VII (FVIIa), fibrinogen, von Willebrand factor antigen (VWF:Ag), and plasminogen activator inhibitor-1 (PAI-1) activity were determined, and their levels were aggregated into a standardized composite index of prothrombotic activity. RESULTS: In bivariate analyses, all HRV indices were inversely correlated with the prothrombotic index explaining between 6% and 14% of the variance (p < 0.001). After controlling for sociodemographic factors, index event, menopausal status, cardiac medication, lifestyle factors, self-rated health, metabolic variables, and heart rate, VLF power, LF power, and HF power explained 2%, 5%, and 3%, respectively, of the variance in the prothrombotic index (p < 0.012). There were also independent relationships between VLF power and PAI-1 activity, between LF power and fibrinogen, VWF:Ag, and PAI-1 activity, between HF power and FVIIa and fibrinogen, and between the LF/HF power ratio and PAI-1 activity, explaining between 2% and 3% of the respective variances (p < 0.05). CONCLUSIONS: Decreased HRV was associated with prothrombotic changes partially independent of covariates. Alteration in autonomic function might contribute to prothrombotic activity in women with coronary artery disease (CAD)

Development of a social support instrument for use in population surveys

A wide variety of measures have been used to assess the effects of social support on physical and psychological well-being. Many instruments have incomplete information about reliability and validity. Other instruments appear to be reasonably valid, but involve a large number of questions and are therefore not suitable in population surveys. The main purpose of the study was to examine whether a psychometrically well documented, but time consuming instrument. The Interview Schedule for Social Interaction, could be abbreviated and simplified for the use in population surveys. By means of both item and content analyses the original instrument was shortened and both versions were tested in a study group of 83 middle-aged Swedish men. The distribution of scale scores were similar in the complete and in the abbreviated version and so was reliability, measured as internal consistency and split-half reliability. Validity was examined by comparing the two versions in relation to other measures of social integration, as well as personality and behaviour characteristics. Men with low social support were less socially and physically active, were more depressed and were less trustful than men with high support. Men who scored low on social support were also more often smokers, of lower social class, lower occupational level and lower education and had more complaints of ill health, mainly of cardiovascular nature. The discriminative capacity was as good for the complete as for the abbreviated version. Thus no obvious disadvantages in terms of reliability and validity could be demonstrated for the abbreviated version.social support social networks social integration measurement psychometric properties cardiovascular risk factors

Gender Considerations in Psychosocial–Behavioral Interventions for Coronary Heart Disease

Six randomized clinical trials (RCT) have been published in major peer review journals, using psychosocial–behavioral interventions with patients who previously experienced major adverse coronary events (MACE). All dealt with important psychological and psychosocial factors that contribute to coronary heart disease (CHD). These RCT obtained either positive or null outcomes for CHD morbidity or mortality. The three RCT reporting positive results (Recurrent Coronary Prevention Project (RCPP), Stockholm Women’s Intervention Trial for CHD (SWITCHD), Secondary Prevention Trial in Uppsala (SUPRIM) used group-based cognitive behavior therapy (CBT), relaxation exercises, coping skills training, and addressed modifiable risk factors and lifestyle planning. Patients began treatment at least 3 months after MACE, received at least 20 intervention sessions, and were followed for an average of 4.5–7.8 years. Therapists were trained in CBT and used manualized treatment. Almost all patients were run in same sex groups. In contrast, the three RCT that obtained null results (WALES, M-HART, ENRICHD) did not use group-based CBT or lifestyle planning for all patients, began behavioral treatment shortly after MACE, provided fewer intervention sessions, and followed patients for an average less than 2.5 years. Whereas patients in the first of the positive trials (RCPP) consisted primarily of men (90 %), the two most recent positive RCT were conducted only with women (SWITCHD) or women and men (SUPRIM) treated in separate sex groups. These RCT were therefore able to focus on problems salient to each sex. Techniques included role playing exercises sensitive to problems important to each sex. This led to group discussions about solving problems germane to these patients. Verbal comments obtained from women, in particular, were positive about such discussions, and both patients and therapists felt that the women could better express themselves in single-sex groups and deal more openly with problems in their lives

Psychosocial Stress and Cardiovascular Disease in Women Concepts, Findings, Future Perspectives

Not long ago, it was assumed that coronary heart disease mainly--or only--affected men. Now that CHD is recognized as a leading killer of women as well as men, numerous research studies have been made of its diverse presentations in women, causal factors, and possibilities for prevention and treatment. The expert contributions to Psychosocial Stress and Cardiovascular Disease in Women span the results of this cross-disciplinary awareness. This progressive resource takes a three-dimensional approach to its subject, focusing on epidemiology and risk factors for heart disease in women, the psycho- and neurobiology of stress and coronary disease, and promising clinical interventions. Chapters identify and analyze multiple intersections of social, biological, and psychological factors in affecting women's heart health, from the social dimensions of depression to genetic/environmental interactions to the demands of balancing work and family. These wide-ranging findings will assist and motivate professionals in choosing and creating interventions, developing appropriate prevention strategies, and reducing gender-based disparities in health care. Among the topics covered: Enhancing women's heart health: a global perspective. Coronary heart disease in women: evolution of our knowledge. Gender observations on basic physiological stress mechanisms in men and women. Sleep as a means of recovery and restitution in women. LifeSkills training: benefiting both genders, for different reasons. Gender considerations in psychosocial-behavioral interventions for coronary heart disease. In particular this book will be helpful for cardiologists and other clinicians who may ask themselves why patients do not seem to make rational choices. "Why do patients not follow the advice they are offered?" is a common complaint. The role of psychosocial stress for patient compliance and adherence can be traced throughout the volume. It is emphasized in the chapters on psychosocial interventions along with other tangible and conceptual suggestions and experiences with psychosocial stress and life style change. Psychosocial Stress and Cardiovascular Disease in Women offers a deep practical level of understanding of this epidemic to help expand the work of health and clinical psychologists, sociologists, cardiologists, primary care physicians, and epidemiologists

Relation of morning serum cortisol to prothrombotic activity in women with stable coronary artery disease

BACKGROUND: Increased circulating cortisol levels have been associated with severity of atherosclerosis. Low-grade systemic thrombogenicity plays a major role in the initiation and progression of coronary disease. We hypothesized a direct relationship between cortisol and hemostasis factors related to a prothrombotic state in coronary artery disease. METHODS: We measured morning serum cortisol and activated clotting factor VII, fibrinogen, von Willebrand factor antigen, and plasminogen activator inhibitor-1 activity in 285 women (56 +/- 7 years) between 3 and 6 months after an acute coronary event. To test whether the relationship between cortisol and hemostasis factors would be independent, statistical adjustment was made for demographic, biomedical, life style, and psychosocial variables. RESULTS: Higher serum cortisol levels predicted higher fibrinogen (beta = .17, P = .001) and higher von Willebrand factor (beta = .16, P = .008), all independently of covariates, including C-reactive protein, which was also an independent predictor of fibrinogen (beta = .20, P = .001) and von Willebrand factor (beta = .16, P = .004). Higher levels of vital exhaustion were associated with higher levels of activated clotting factor VII independently of covariates and depression (beta = .18, P = .045). Cortisol showed crude correlations with vital exhaustion (r = .14, P = .022) and with depression (r = .13, P = .043) but did not mediate the relationship between psychosocial variables and hemostatic factors. CONCLUSIONS: Morning serum cortisol showed a modest but independent association with prothrombotic activity in women with coronary artery disease suggesting that increased cortisol levels might contribute to atherosclerosis via eliciting a hypercoagulable state