AIM: To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain. DESIGN: All patients were sent a postal questionnaire for symptom evaluation. SUBJECTS: All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904). RESULTS: 88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P
Comparing American and Canadian practice patterns and outcomes offers a natural experiment to examine the relative benefits of aggressive versus conservative management of coronary artery disease. In a prospective substudy of the Global Use of Strategies to Open Occluded Coronary Arteries IIb (GUSTO-IIb) trial, differences in the management of non-ST elevation acute coronary syndrome, and the associated impact on quality of life (QOL) outcomes, were examined in the two countries.
The patient population, selected randomly from the parent trial population, comprised 390 Canadian and 1122 American patients for whom both baseline and one-year data were available. Validated instruments were used to assess QOL, including the Duke Activity Status Index (DASI) and scales from the SF-36 questionnaire. At baseline, American patients had significantly higher cardiac catheterization rates (83% versus 45%), percutaneous coronary intervention rates (39% versus 24%) and coronary bypass surgery rates (19% versus 12%) than did Canadian patients, respectively. However, at one year, Canadian coronary bypass surgery rates were at par with those in the United States (24% versus 26%, respectively). At baseline, the mean DASI score was 24.6 among Canadian patients and 23.4 among American patients (P=0.14). At one year, neither cohort reported any significant change in functional scores and there was no intercountry difference in DASI scores, even after accounting for baseline risk. Canadian patients had significantly worse mental health scores than American patients at baseline (mean score 71.6 versus 75.4, respectively; P=0.02), but by one year, Canadian patients had better scores (mean score 80.1 versus 76.2, respectively; P=0.01). After adjusting for baseline characteristics, Canadian patients continued to report better mental health status scores than did American patients (4 points higher, P
Cardiac procedures are performed less frequently in Canada than in the United States (US), yet rates of cardiac death and myocardial infarction are similar. We therefore sought to compare long-term symptoms and quality of life in Canadian and American patients undergoing initial coronary revascularization. The 161 patients enrolled in the Bypass Angioplasty Revascularization Investigation at the Montreal Heart Institute were compared with 934 patients enrolled at 7 US sites. Patients' outcomes were documented for 5 years after random assignment to percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery. Functional status was assessed using the Duke Activity Status Index. Canadian patients were significantly younger and had more angina at study entry. Death and nonfatal myocardial infarction were not significantly different between Canadian and US patients after adjustment for baseline risk. Canadian patients had significantly greater improvements in functional status at 1-year follow-up (Duke Activity Status Index score + 13.5 vs. + 6.0, p = 0.002), but this difference progressively narrowed over 5 years. Angina was equally prevalent in Canadian and US patients at 1 year (16% vs. 19%), but significantly more prevalent in Canadian patients at 5 years (36% vs. 16%, p = 0.001). Repeat revascularization procedures were performed less often over 5 years among Canadian patients (26% vs. 34%, p = 0.08), especially coronary artery bypass graft surgery after initial percutaneous transluminal coronary angioplasty (18% vs. 32%, p = 0.03). These results suggest more anginal symptoms are required in Canada before coronary revascularization, but as a result Canadians receive greater improvements in quality of life after the procedure.
Psychosocial factors are increasingly recognized as risk indicators for coronary artery disease (CAD) prognosis and they are likely interrelated. The objective of this study is to simultaneously test the relationship between key psychosocial constructs as independent factor scores and recurrent events in CAD patients. There were 1268 CAD outpatients of 97 cardiologists surveyed at two points. Recurrent events or hospitalization in the intervening nine months were reported. Factor analysis of items from the Hospital Anxiety and Depression Scale, Perceived Stress Scale, the ENRICHD Social Support Inventory, and Hostile Attitudes Scale was performed to generate orthogonal factor scores. With adjustment for prognostic variables, logistic regression analysis was performed to examine the relationship between these factor scores and recurrent events. Factor analysis resulted in a six-factor solution: hostility, stress, anxiety, depressive symptoms, support, and resilience. Logistic regression revealed that functional status and anxiety, with a trend for depressive symptoms, were related to experiencing a recurrent event. In this simultaneous test of psychosocial constructs hypothesized to relate to cardiac prognosis, anxiety may be a particularly hazardous psychosocial factor. While replication is warranted, efforts to investigate the potential benefits of screening and to investigate treatments are needed.
In clinical trials, cholesterol-lowering medications have been proven to decrease mortality and morbidity and are strongly recommended as secondary prevention for patients with established coronary artery disease. Whether physicians and patients follow this recommendation is unknown. Our objective was to determine the rate at which patients fill at least one prescription for cholesterol-lowering medications after coronary revascularization.
Using the computerized administrative databases of the Régie de l'assurance maladie du Québec, we identified all elderly patients (older than 65 years) who had a coronary revascularization procedure (percutaneous coronary intervention or coronary artery bypass graft) between Apr. 1, 1995, and Dec. 31, 1997, and who survived until hospital discharge. We also determined the percentage of these patients who filled one or more prescriptions for cholesterol-lowering drug therapy before Dec. 31, 1999, or death, whichever date came first. We used multivariate logistic regression models to examine the independent associations between filling a prescription for a cholesterol-lowering drug, patient characteristics and the type and year of coronary revascularization.
We identified 11 958 elderly patients who had a coronary revascularization between Apr. 1, 1995, and Dec. 31, 1997. During a follow-up period that averaged 3 years, 4443 (37.2%) patients did not fill a prescription for a cholesterol-lowering medication. Patients who were male, of advanced age, who had diabetes or congestive heart failure were less likely to fill a prescription for a cholesterol-lowering medication. Patients whose initial revascularization procedure was coronary artery bypass grafting were also less likely than those who had angioplasty to start cholesterol-lowering medication (relative risk [RR] 0.77, 95% confidence interval [CI] 0.73 - 0.81). Use of cholesterol lowering medications before the revascularization procedure was very strongly associated with future drug use (RR 7.20, 95% CI 6.83-7.58).
In this population-based study of revascularized patients, we observed a substantial underutilization of cholesterol-lowering medications after revascularization. Our observations suggest an important role for continuity of care in the treatment of cardiovascular patients undergoing revascularization procedures.
Cites: N Engl J Med. 1993 Mar 18;328(11):779-848123063