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Medical and psychosocial outcomes in survivors of major heart surgery
Journal
of Psychosomatic Britain.
Printed in Great
Research, Vol.23,No.3,pp.213-221, 1981
MEDICAL
AND PSYCHOSOCIAL
SURVIVORS
OUTCOMES
IN
OF MAJOR HEART SURGERY*
STEPHEN J. ZxzANsKI,-f C. DAVID JENKINS+ (Received 29 October
0022.3999/81/030213-09$02.00/O 0 1981 Pergamon Press Ltd.
BABETTE A. STANTON, +
and MICHAEL D. KLEIN§
1980; accepted in revisedform
21 February
1981)
Abstract-To assess long-term recovery following major heart surgery, medical and psychosocial outcomes were studied by mailed questionnaire in a sample of 949 patients (724 coronary bypass, 147 mitral and 78 aortic valve) drawn from the membership of Mended Hearts, a nationwide (U.S.A.) voluntary organization of persons having had heart surgery. Survey data were scaled and scored for reported changes, preoperative to present, in psychological and social adjustment, and for current emotional status, social network and employment. Medical outcomes included rehospitalization, repeated heart surgery, continuation of angina and dyspnea and limitations of activity requiring bed rest. Although about half of the respondents had been rehospitalized in the average 3% year interval since surgery, over 90% were currently free of frequent serious angina or dyspnea and disability requiring bed rest. Post-operative medical complications were more common among persons forced to retire from work, those having Type A behavior, and women with multiple vessel bypasses. Even after seven biomedical variables were controlled statistically, psychosocial outcomes were clearly worse in these same three groups. The findings have implications for patient selection and for post-operative care.
no exact data are available, authorities estimate that over 110,000 major heart operations were performed in 1978 in the United States and the frequency has been steadily increasing. Coronary bypass surgery accounted for the majority of these procedures, and surgical repair or replacement of mitral and aortic valves was next most common. The success of major cardiac surgery in adults has been measured in terms of reduction in mortality and relief of symptoms of dyspnea and angina [l]. Less frequently, psychological and behavioral factors have been investigated, both as predictors of postoperative course [2-71 and as outcome measures [8-121. The latter studies have tended to show that psychological impairments greatly outnumber physical impairments. In many instances, however, these studies have been conducted with small numbers of patients, or have been limited to patients having valvular disease. The present study was designed to provide a more comprehensive understanding of the many aspects which comprise successful long-term recovery in large numbers of coronary bypass as well as cardiac valve patients. Its specific aims were to: (1) identify the major social and psychological barriers to complete recovery in preparation for a more intensive prospective study; (2) compare and contrast coronary bypass and cardiac valve patients in terms of the psychosocial and bio-medical outcomes they experience; (3) search for variables which might be important influences upon postoperative recovery, and (4) determine whether the frequency WHILE
*This research was supported in part by Mended Hearts, Inc. and by research grant HL 20637 from the National Heart, Lung and Blood Institute. TDepartment of Family Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio, U.S.A. To whom correspondence should be addressed. *Department of Behavioral Epidemiology, Boston University School of Medicine, Boston, Massachusetts, U.S.A. 5 Department of Cardiology, Boston University School of Medicine, Boston, Massachusetts, U.S.A. 213
214
STEPHEN J. ZYZANSKI, BABETTEA. STANTON, C. DAVID JENKINS and MICHAEL D. KLEIN
of psychosocial problems is strictly a function of the severity of biomedical or whether other ‘risk factors’ can be identified.
problems
METHODS
Sample characteristics A 25% random sample was drawn from among the former surgery patients
listed on the membership rolls of each chapter of Mended Hearts, Inc., a self-help group operating throughout the United States. Each selectee was mailed a pre-coded, eight page questionnaire and form to indicate consent for participation. Of the 1400 questionnaires mailed, over 1100 were returned for a response rate of 80.6%. The high rate of return suggests the respondents were likely to be quite representative of the total group membership. We also know that the sample studied represents patients from all sections of the U.S.A. who had surgery performed in hospitals with low volumes of heart surgery, as well as large-volume medical centers. Only those patients having coronary artery bypass grafts or mitral or aortic valve surgery were included in the present analysis. Persons who had surgery to repair congenital anomalies were excluded, as were those having rare or minor procedures (e.g. implantation of a pacemaker). This restricted the population to 949 adults of which approximately j’/4were men and 3/4 were between the ages of 50 and 69 years. Only about 4% were under the age of 40 and another 4% were over the age of 70. The distribution of patients by sex, type of surgery and the average age and years since surgery for each group are displayed in Table 1. The average coronary bypass respondent underwent surgery at about age 54 and the average cardiac valve respondent had surgery between ages 47 and 50.
TABLE 1 .-MEAN
AGE
AND YEARSSINCE SURGERYBY SEXAND TYPE OF SURGERY
FOR 949 POST-OPERATIVEPATIENTS
Type of surgery
Sex
1 Vessel bypass
Males Females Males Females Males Females Males Females Males Females
2 Vessel bypass 3 Vessel bypass Mitral valve Aortic valve Totals
Sample size
Present age
10 3 26 5 29 3 5 11 5 3
98 29 245 46 278 28 44 103 53 25
56.1 58.2 56.9 58.0 57.1 56.2 57.1 54.7 54.4 57.8
3.7 3.0 3.5 2.1 2.9 3.0 1.0 8.0 5.3 6.8
100
949
56.7
3.5
%
Years since surgery
Overall, 76% of the respondents had bypass surgery, 16% mitral valve surgery, and 8% aortic valve surgery. The sex ratios for these various procedures were quite different. For example, six times as many men as women had coronary artery bypass, twice as many men as women had aortic valve repair, but less than half as many men as women had mitral valve surgery. The length of time since surgery averaged 3 years for bypass patients, but about twice as long for valve surgery patients. A total of 8% of patients had two different surgical procedures performed at the time of their first surgery. The most common combination was repair to both the mitral and aortic valve. Repair of aneurysms was also a relatively common second procedure.
Development of indices Data were collected by an eight page survey questionnaire containing mostly preceded items. The few items calling for short, written answers were coded according to a standard protocol. The questionnaire contained a broad array of items covering demographic and social background, life circumstances before surgery, the surgical experience, emotional and social status the first year after surgery, and appraisals of current physical and emotional health and social relationships and economic matters. Occupational level before and after surgery was also investigated. The coronary-prone behavior pattern (Type A) was estimated by a brief ad hoc scale abstracted from the Jenkins Activity Survey [13]. This
Medical and psychosocial
outcomes
in survivors
of major heart surgery
215
behavior pattern is an aggressive, competitive, hurried, intensely active personal style which has been found associated with incidence, prevalence and recurrence of coronary heart disease. Two scales were developed from items asking patients to compare their circumstances before surgery with those one year after surgery. These scales, created especially for this study, dealt with psychological or affect changes and social adjustment changes. Two additional scales were developed from items asking for evaluation of current emotional state and current social network. Scale scores for these four components were derived by coding 0 for item responses indicating a negative outcome and coding 1 for neutral or positive responses. The codes were summed for each scale for each person (adjusted for missing data where necessary) to provide total scale scores. All scale scores were transformed to standard scores having a mean of 50 and a standard deviation of 20, so as to provide a common metric for comparing all results. Greater mean values reflect positive outcomes and scores less than 50 indicate relative impairment of recovery. The first behavioral change scale, “Psychological or Affect Changes After Heart Surgery”, contains six items pertaining to changes in feelings of depression, anxiety, pleasure in life and optimism, from one year prior to surgery to the present. The second behavioral change scale, “Social Adjustment Changes After Heart Surgery”, has ten items dealing with changes in relationships between patient and spouse, children, relatives and coworkers. The third scale, “Current Emotional State”, has eleven items pertaining to feelings during the past month of anxiety, nervousness, restlessness, sadness, happiness, contentment, the perception that psychological problems were interfering with recovery, and the patient’s use of tranquilizers and sleeping pills. The final nine-item scale, labeled “Current Social Network”, is based on current marital status, size of household, attendance at organizational meetings or religious services, perceived affection received from family members and family’s response during recovery (i.e. overprotection, adequate support, isolation or avoidance). The average correlations between each item and the sum of the remaining items in its scale for the four scales, respectively, were: 0.79, 0.67, 0.60 and 0.50.
RESULTS Between the time of initial surgery and response to the survey, an average of 3% years, these 949 patients experienced a variety of medical problems. These are summarized in Table 2. Hospitalization since surgery was reported by 51% of the patients. Over half of the patients (64%) were hospitalized for various cardiovascular problems, including arrhythmias. This includes the 12% of all persons who reported being hospitalized for heart attack. Thirteen per cent of all patients were admitted for gastrointestinal disorders and the remaining 23% were hospitalized for other difficulties. TABLE 2.-RATESOF
~ELE~TEDI~ED~~ALOUTCOMESBYSEXANDTYPEOFSURGERY
% with Sample second size surgery
% hospitalized since surgery
% with heart-related hospitalization
% with current severe and recurring pain or dyspnea
% reporting three or more days in bed last month
1 Vessel
Males Females
98 29
8 7
57 48
34 34
6 10
7 14
2 Vessels
Males Females
245 46
4 7
50 54
29 39
3 9
4 15
3 Vessels
Males Females
278 28
3 11
42 71
28 54
3 11
6 18
Mitral valve
Males Females
44 103
23 22
59 60
48 38
2 3
5 10
Aortic valve
Males Females
53 25
13 16
47 68
36 44
2 0
8 12
949
8
51
33
4
7
Total sample
A second major heart operation was sustained by 8% of all respondents. This rate varied greatly by the type of initial surgical procedure. Less than 5% of all bypass patients sustained second surgery, but 14% of aortic patients and 22% of mitral valve patients had a second surgical episode. This may have been influenced by the longer average period the valve patients had between surgery and follow-up study.
216
STEPHEN J.
ZYZANSKI,
BABETTE
A.
STANTON,
C. DAVID
JENKINS
and MICHAEL D. KLEIN
The percentages of persons experiencing severe and recurring symptoms of their heart condition in the past month and those requiring three or more days of bed rest in the past month are gratifyingly low, suggesting an excellent therapeutic result of surgery, on the average. Among bypass patients, a higher percentage of women than men reported severe recurring chest pain or dyspnea. For all types of surgery, women were confined to bed in the past month twice as frequently as men. Table 3 presents a series of analyses examining relationships between postoperative medical and postoperative psychosocial outcomes. Consistent decreases in psychosocial functioning were observed in patients experiencing postoperative heart-related hospitalization, other major (non-cardiac) health problems, continuing and intense chest pain and illness-related bed rest. TABLE
3.-AVERAGE
PSYCHOSOCIAL
Medical variables
OUTCOME
SCORES AS THEY
Response
(N)
Hospitalized post-operatively MI or valve problem Other heart problem Non-heart problem Not hospitalized
Yes Yes Yes Yes
101 214 172 462
Other major health problems (non-heart)
Yes No
253 696
More than 3 days sick in bed this month
Yes No
69 880
Continuing
Yes No
38 911
o-2 3-4 5-9 10+
338 330 213 64
intense chest pain
Years since surgery
Psychological change
RELATE
TO MEDICAL
Psychosocial Emotional status
41.1 45.5 52.0 53.3 t
ASPECTS
OF RECOVERY
outcomes Social adjustment
Social network
-
-
+
* = P< 0.05 (F-test). + = PCO.01. $ = P
Medical and psychosocial
outcomes
in survivors
of major
heart surgery
217
TABLE 4.-FACTORS AFFECTINGEMOTIONALCHANGESAFTER HEART SURGERY (standard scores (mean = 50) adjusted for 9 medical covariates) Sex Type of surgery
N
Male
Female
1 Vessel bypass 2 Vessel bypass 3 Vessel bypass Mitral valve Aortic valve
127 291 306 147 78
51.5 50.9 48.5 49.0 48.1
52.5 44.6 39.1 53.4 59.8
Forced retirement
Forced.to Not forced, but not working retire (N= 109) (N= 50)
(Limited to persons under 61 years)
44.7
Type A Behavior
type
(N=351)
47.4 Intermediate (N = 296)
Currently working (N=380)
51.9
F
P
6.9
0.001
Type B (N= 302) 53.0
48.8
48.4
Interaction: F= 4.0 P < 0.003 d.f. =4
F ’ 5.0
P 0.007
TABLE 5.-FACTORS AFFECTING SOCIAL ADJUSTMENT CHANGES AFTER HEART SURGERY(standard scores (mean = 50) adjusted for 9 medical covariates) Sex Level of education Some H.S. or less H.S. grad or added training Some college College grad or post-grad
Forced retirement (Limited to persons under 61 years)
N
Male
Female
138
51.3
56.5
357 254
51.2 48.3
47.2 53.4
200
47.9
52.1
Forced to Not forced, retire but not working (N= 109) (N= 50)
44.1
48.4
Currently working (N=380)
52.0
Interaction: F=2.7 P=O.O5 d.f. = 3 Main effects Education: N.S. Sex: N.S.
F
P
10.7
0.001
type of surgery, forced retirement, and Type A behavior pattern) remained significantly associated with the outcome scale score after nine medical covariates were statistically controlled. The medical covariates are: (1) number of surgical procedures performed at the initial surgery; (2) current age; (3) time since surgery; (4) rehospitalization since surgery; (5) heart-related hospitalizations (e.g. MI and CHF); (6) second heart surgery; (7) presence of continuing health problems not related to the heart; (8) current severe and recurring pain, and (9) having spent three or more days sick in bed in the past month. The search for predictors of postsurgical changes in emotional adjustment is summarized in Table 4. Changes in levels of anxiety, depression and general emotional state after heart surgery were significantly related to sex, type of surgery, forced retirement and coronary-prone behavior pattern. The significant “sex by type of surgery” interaction indicates that female multiple bypass patients, more than male bypass or female valve surgery patients, were likely to report that emotionally they felt worse now than they did one year prior to surgery. Patients who were clearly Type A personalities or intermediate in behavior type also experienced significantly more negative emotional changes than those categorized as Type B.
218
STEPHENJ. ZYZANSKI, BABETTEA. STANTON,C. DAVID JENKINSand MICHAELD. KLEIN
For the “forced retirement” variable, statistical analysis was limited to those patients 60 years of age or younger to permit an adequate time period for returning to work which would not overlap with usual retirement ages. The results shown in Table 4 indicate that persons forced to retire experienced significantly more negative emotional changes subsequently than either persons currently working or those not working, but not forced to retire. Some factors affecting social adjustment changes after heart surgery are shown in Table 5. The patients experiencing the most negative changes in personal relationships with spouse, family and coworkers were persons of either sex reporting forced retirement, female high school graduates, and males with college education. Despite the clinical expectation that valve and bypass patients would differ in postoperative social adjustment changes, analysis of the data showed this not to be the case. A multivariate analysis (not presented in a table) revealed that behavior type and forced retirement remained significant correlates of current emotional status after adjustment for the medical co-variates. Persons classified as Type A personalities reported significantly more feelings of anxiety, depression, discouragement and restlessness in the past month (mean standard score = 46.2) than persons classified as Type B (mean score = 53.2, significance of difference, P = 0.001). Their current outlook, on the average, seems to be one of frustration and unrealized expectations. The final analysis revealed the strong effects of forced retirement on postoperative outcomes, in this case, present emotional status. Those currently working were relatively happy and cited the fewest psychological problems (mean standard score = 51.5). Those not working for reasons other than forced retirement were almost equal to the currently employed in their emotional status (mean = 50.3). Those forced into early retirement, however, reported that significant emotional difficulties were interfering with their recovery (mean = 47.7, significance of difference, P = 0.008). Thus, forced retirement seems to be related to negative changes in emotional and social adjustment, and to the emotional adjustment of patients by an average of 3% years postoperatively. Whether some of these negative changes might have preceded rather than followed the forced retirement cannot be determined from this retrospective design. Low scores on the scale, “Current Social Network”, represent deficits in psychosocial supports, including living alone, lack of participation in community activities, family withdrawal and lack of affection. These deficits are most common in females (P = O.Ol), Type A persons (P = 0.03), and those with lower levels of education (P = 0.02).
DISCUSSION
This study represents a preliminary effort to identify the various facets of postoperative recovery which are important to patients, and to their physicians, families and communities. We have developed sets of survey questions to elicit patients’ experiences of physical and psychological symptoms, interpersonal relationships, occupational activity and adjustment, financial situation, and other issues of adjustment deemed important by our consultant panel of heart surgery patients. While these methods still need refinement, we believe that this work represents progress in broadening the operational definition of recovery far beyond the traditional criteria of survival and unstructured questioning about relief from pain. The items appeared to be well comprehended by this large population of people from many backgrounds, as judged by the logical consistency of responses which our data editing revealed. The items and developed scales also had good distributional properties. Survey methodology of this sort seems to be a practical and quite reliable approach to defining and estimating the various socially relevant facts of recovery in large study populations. To what degree do the findings here reported adequately estimate the experience of the total population of survivors of these types of heart surgery? There is no existing enumeration of this population, and hence, we could neither sample from it nor determine what differences might exist between it and the population we studied. The membership of Mended Hearts, Inc., might be unrepresentative of the total, but the degree of bias may not be as great as first suspected. The socioeconomic data suggest that compared to the general U.S. population in this age
Medical and psychosocial
outcomes
in survivors
of major heart surgery
219
range, this organization’s membership has a higher education level (48% with at least some college education, and only 15% who did not complete high school) and higher presurgical occupational status (70% in Hollingshead Occupational ratings l-4). If major heart surgery is more readily available to middle and upper class persons, it is possible that the population of U.S. heart surgery patients may differ from the general population in the same direction. Most of these respondents came from cohorts of patients whose surgery was performed since 1970, and hence loss from the sample due to death since surgery seems acceptably low. In terms of the influence course of recovery has on entry into Mended Hearts, Inc., the impressions of the organization leaders and the authors are that persons with poor initial courses of recovery, particularly those with continuing severe disability, are less likely to join the organization. These sources of bias tend to be counterbalanced somewhat by the fact that persons who return quickly into full-time employment and to their established social activities often feel that they have no further need for a patient organization and drop out of membership. Respondents to this survey had belonged to Mended Hearts for an average of 2% years. Response did not seem to be determined by level of activity in the organization, in that over a quarter never attended meetings, and another quarter attended only once or twice per year. These persons may not be dissimilar to former heart surgery patients who are not members of this organization. Thus it appears that the organizational membership lists represent a distribution of recovery outcomes truncated at the extremes, and perhaps thereby the mean level of recovery is not too seriously displaced from the true, but unknown population mean. Certain aspects of the sample lend encourgement as to its adequacy. The high response rate of 80%, achieved with only one reminder letter, suggests that the respondents are at least highly representative of this organization. It is also reassuring that the age-range and the proportions of men and women in our sample agree with other estimates of age-sex prevalences by type of surgery. Problems of recall of data were also taken into account by the time-frame of different types of questions. Softer items (those less objective and less well remembered), such as symptoms and perceptions, tended to be focused on the most recent month, except for some of the pre- vs. postsurgery comparison items. For harder data, such as hospitalizations, or occurrence of a heart attack, the time frame for recall was extended back to the date of heart surgery, a period of 4 years or less for 75% of the sample. In general, however, longer periods of recall are associated with the forgetting of events, and hence the reported frequencies of past medical complications are more likely to underestimate rather than overestimate their true prevalence. Nevertheless, despite these efforts to minimize systematic bias, caution in interpretation is warranted because these data are derived from patients’ self-reports of state of health in a retrospective study. We believe, however, that these data provide a relatively trustworthy basis for planning, at least until comprehensive prospective study data can be developed. A number of the findings deserve additional discussion. Inquiry regarding postoperative medical status revealed what seemed to be a rather high frequency of hospitalization-over 50% of persons had been hospitalized one or more times
220
STEPHEN J. ZYZANSKI, BABETTEA. STANTON, C. DAVID JENKINSand MICHAEL D. KLEIN
in the average elapsed time of 3 l/z years. Chronic gastrointestinal problems seemed particularly common. This finding deserves further investigation to see whether the array of orally administered drugs commonly prescribed for these patients may be contributing factors. The frequency of severe dyspnea and angina was gratifyingly low, suggesting a high rate of continuing effectiveness of the surgical correction. The findings that physical medical problems are correlated with poor psychosocial outcomes was expected. What was uncertain was whether additional indicators such as sex, type of surgery, level of education, forced retirement, or the Type A behavior pattern would be associated with psychosocial outcomes after the impact of physical medical problems had been accounted for. The direct relationship of these five variables to poor recovery outcomes is further supported by the fact that these predictors were also significant in the subgroup of patients who had none of the seven major postoperative physical health problems covered by the study. Forced retirement can cause a severe loss of self-esteem and self-acceptance and interfere with emotional adjustment in persons, such as Type A’s, for whom occupational role is central to self-concept. For many persons, employment provides more than just a livelihood. It also provides a social network and a variety of psychological gratifications. Focused study is needed to discover the reasons why women undergoing multiple bypass procedures tend to experience worse medical and psychological outcomes than men undergoing the same procedures or women having valve surgery. It may be that a substantial fraction of these women have either small vessel disease or cardiospasm, neither of which was corrected by surgery. The implications of these findings are several. Many aspects of these data indicate that heart surgery does not cause a permanent negative change in the social or psychological situation of most patients. On the contrary, of those with long-term changes from their preoperative levels, far more reported improvement than decline on all psychosocial indices studied, except for economic condition. Anecdotal reports point to excessive administrative difficulties and delays in obtaining disability payments and other federal and state benefits as contributing to the economic problems of some patients. Physical health problems and certain psychosocial factors contribute separately and independently to poor emotional state and poor social adjustment after surgery. It may also be that psychosocial factors contribute to physical health problems, but our study design and data analyses could not address this issue. The data suggest that efforts to prevent forced retirement after heart surgery might contribute substantially to improving overall recovery. The directionality of this relationship is suggested by the fact that persons forced to retire showed more problems than those not working for other reasons. The statistical control for postoperative medical problems supports the conclusion that the poor psychosocial recovery in those forced to retire was not attributable to their being physically sicker. Corporate policies and rehabilitative programs should be aimed at fostering return to work for heart surgery patients. This may sometimes require a change in the physical and emotional demands of the job. The finding regarding the poorer adjustment of Type A persons may in part derive from these persons having more severe atherosclerosis than Type B’s and hence more seriously compromised coronary vasculature [14]. In addition the
Medical and psychosocial
outcomes
in survivors
of major heart surgery
221
impatient, striving, perfectionistic demands the Type A patient places upon himself tend to set the stage for disappointment and resentment over the pace of recovery. It might be useful to attempt patient education aimed at instilling realistic expectations regarding recovery, and individual counselling or group therapy to reduce intensity of the Type A pattern, and to deal with the episodes of anxiety, anger and depression to which the Type A persons seem, from these data, to be more susceptible. These intervention efforts should be evaluated both to see if they achieve their immediate therapeutic aims and if they improve the long-term psychosocial aspects of recovery. REFERENCES bypass grafting. Circulation 1. MCINTOSH H. D. and GARCIA J. A. The first decade of aortocoronary 57,405 (1978). responses to open-heart surgery. Nurs. Res. 21,220 (1972). 2. ELSBERRYN. L. Psychological to cardiac surgery. J. Thoruc. Surg. 58, 891 (1969). 3. KIMBALLC. P. A predictive study of adjustment 4. KIMBALL C. P. Psychological responses to the experience of open-heart surgery. Part 1. Am. J. Psychiat. 126,348 (1969). Psychosom. 5. TUFO H. M. and OSTFELD A. M. A prospective study of open-heart surgery (abstracted). Med. 30,552 (1968). adjustment and acute response 6. HENRICHS T. F., MCKINZIE J. W. and ALMOND C. H. Psychological to open-heart surgery. J. New. Ment. Dis. 148,158 (1969). 7. KILPATRICK D. G., MILLER W. C., ALLAIN A. N., HUGGINS M. B. and LEE JR. W. H. The use of psychological test data to predict open-heart surgery outcome: a prospective study. Psychosom. Med. 37,62 (1975). 8. BLACHLY P. H. and BLACHLY B. J. Vocational and emotional status of 263 patients after heart surgery. Circulation 38,524 (1968). 9. LUCIA W. and M&WIRE L. B. Rehabilitation and functional status after surgery for valvular heart disease. Archs Intern. Med. 126,995 (1970). 10. FRANK K. A., HELLER S. S. and KORNFELD D. S. A survey of adjustment to cardiac surgery. Archs Intern. Med. 130, 735 (1972). 11. HELLER S. D., FRANK K. A., KORNFELD D. S. and MALM JR., F. 0. Psychological outcome following open-heart surgery. Archs Intern. Med. 134,908 (1974). 12. GUNDLE M. J., BOZMAN R. R., TATE S., RAFT D. and MCLAURIN L. P. Psychosocial outcome of coronary artery surgery. Presented at the meeting of the American Psychiatric Association, Chicago, Illinois, 11-18 May, 1979. 13. JENKINS C. D., ZYZANSKI S. J. and ROSENMAN R. H. The Jenkins Activity Survey for Health Prediction. Boston, Massachusetts (1972). 14. ZYZANSKI S. _I., JENKINS C. D., RYAN T. .I., FLESSASA. and EVERIST M. Psychological correlates of coronary angiographic findings. Archs Intern. Med. 136, 1234 (1976).
of Psychosomatic Britain.
Printed in Great
Research, Vol.23,No.3,pp.213-221, 1981
MEDICAL
AND PSYCHOSOCIAL
SURVIVORS
OUTCOMES
IN
OF MAJOR HEART SURGERY*
STEPHEN J. ZxzANsKI,-f C. DAVID JENKINS+ (Received 29 October
0022.3999/81/030213-09$02.00/O 0 1981 Pergamon Press Ltd.
BABETTE A. STANTON, +
and MICHAEL D. KLEIN§
1980; accepted in revisedform
21 February
1981)
Abstract-To assess long-term recovery following major heart surgery, medical and psychosocial outcomes were studied by mailed questionnaire in a sample of 949 patients (724 coronary bypass, 147 mitral and 78 aortic valve) drawn from the membership of Mended Hearts, a nationwide (U.S.A.) voluntary organization of persons having had heart surgery. Survey data were scaled and scored for reported changes, preoperative to present, in psychological and social adjustment, and for current emotional status, social network and employment. Medical outcomes included rehospitalization, repeated heart surgery, continuation of angina and dyspnea and limitations of activity requiring bed rest. Although about half of the respondents had been rehospitalized in the average 3% year interval since surgery, over 90% were currently free of frequent serious angina or dyspnea and disability requiring bed rest. Post-operative medical complications were more common among persons forced to retire from work, those having Type A behavior, and women with multiple vessel bypasses. Even after seven biomedical variables were controlled statistically, psychosocial outcomes were clearly worse in these same three groups. The findings have implications for patient selection and for post-operative care.
no exact data are available, authorities estimate that over 110,000 major heart operations were performed in 1978 in the United States and the frequency has been steadily increasing. Coronary bypass surgery accounted for the majority of these procedures, and surgical repair or replacement of mitral and aortic valves was next most common. The success of major cardiac surgery in adults has been measured in terms of reduction in mortality and relief of symptoms of dyspnea and angina [l]. Less frequently, psychological and behavioral factors have been investigated, both as predictors of postoperative course [2-71 and as outcome measures [8-121. The latter studies have tended to show that psychological impairments greatly outnumber physical impairments. In many instances, however, these studies have been conducted with small numbers of patients, or have been limited to patients having valvular disease. The present study was designed to provide a more comprehensive understanding of the many aspects which comprise successful long-term recovery in large numbers of coronary bypass as well as cardiac valve patients. Its specific aims were to: (1) identify the major social and psychological barriers to complete recovery in preparation for a more intensive prospective study; (2) compare and contrast coronary bypass and cardiac valve patients in terms of the psychosocial and bio-medical outcomes they experience; (3) search for variables which might be important influences upon postoperative recovery, and (4) determine whether the frequency WHILE
*This research was supported in part by Mended Hearts, Inc. and by research grant HL 20637 from the National Heart, Lung and Blood Institute. TDepartment of Family Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio, U.S.A. To whom correspondence should be addressed. *Department of Behavioral Epidemiology, Boston University School of Medicine, Boston, Massachusetts, U.S.A. 5 Department of Cardiology, Boston University School of Medicine, Boston, Massachusetts, U.S.A. 213
214
STEPHEN J. ZYZANSKI, BABETTEA. STANTON, C. DAVID JENKINS and MICHAEL D. KLEIN
of psychosocial problems is strictly a function of the severity of biomedical or whether other ‘risk factors’ can be identified.
problems
METHODS
Sample characteristics A 25% random sample was drawn from among the former surgery patients
listed on the membership rolls of each chapter of Mended Hearts, Inc., a self-help group operating throughout the United States. Each selectee was mailed a pre-coded, eight page questionnaire and form to indicate consent for participation. Of the 1400 questionnaires mailed, over 1100 were returned for a response rate of 80.6%. The high rate of return suggests the respondents were likely to be quite representative of the total group membership. We also know that the sample studied represents patients from all sections of the U.S.A. who had surgery performed in hospitals with low volumes of heart surgery, as well as large-volume medical centers. Only those patients having coronary artery bypass grafts or mitral or aortic valve surgery were included in the present analysis. Persons who had surgery to repair congenital anomalies were excluded, as were those having rare or minor procedures (e.g. implantation of a pacemaker). This restricted the population to 949 adults of which approximately j’/4were men and 3/4 were between the ages of 50 and 69 years. Only about 4% were under the age of 40 and another 4% were over the age of 70. The distribution of patients by sex, type of surgery and the average age and years since surgery for each group are displayed in Table 1. The average coronary bypass respondent underwent surgery at about age 54 and the average cardiac valve respondent had surgery between ages 47 and 50.
TABLE 1 .-MEAN
AGE
AND YEARSSINCE SURGERYBY SEXAND TYPE OF SURGERY
FOR 949 POST-OPERATIVEPATIENTS
Type of surgery
Sex
1 Vessel bypass
Males Females Males Females Males Females Males Females Males Females
2 Vessel bypass 3 Vessel bypass Mitral valve Aortic valve Totals
Sample size
Present age
10 3 26 5 29 3 5 11 5 3
98 29 245 46 278 28 44 103 53 25
56.1 58.2 56.9 58.0 57.1 56.2 57.1 54.7 54.4 57.8
3.7 3.0 3.5 2.1 2.9 3.0 1.0 8.0 5.3 6.8
100
949
56.7
3.5
%
Years since surgery
Overall, 76% of the respondents had bypass surgery, 16% mitral valve surgery, and 8% aortic valve surgery. The sex ratios for these various procedures were quite different. For example, six times as many men as women had coronary artery bypass, twice as many men as women had aortic valve repair, but less than half as many men as women had mitral valve surgery. The length of time since surgery averaged 3 years for bypass patients, but about twice as long for valve surgery patients. A total of 8% of patients had two different surgical procedures performed at the time of their first surgery. The most common combination was repair to both the mitral and aortic valve. Repair of aneurysms was also a relatively common second procedure.
Development of indices Data were collected by an eight page survey questionnaire containing mostly preceded items. The few items calling for short, written answers were coded according to a standard protocol. The questionnaire contained a broad array of items covering demographic and social background, life circumstances before surgery, the surgical experience, emotional and social status the first year after surgery, and appraisals of current physical and emotional health and social relationships and economic matters. Occupational level before and after surgery was also investigated. The coronary-prone behavior pattern (Type A) was estimated by a brief ad hoc scale abstracted from the Jenkins Activity Survey [13]. This
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behavior pattern is an aggressive, competitive, hurried, intensely active personal style which has been found associated with incidence, prevalence and recurrence of coronary heart disease. Two scales were developed from items asking patients to compare their circumstances before surgery with those one year after surgery. These scales, created especially for this study, dealt with psychological or affect changes and social adjustment changes. Two additional scales were developed from items asking for evaluation of current emotional state and current social network. Scale scores for these four components were derived by coding 0 for item responses indicating a negative outcome and coding 1 for neutral or positive responses. The codes were summed for each scale for each person (adjusted for missing data where necessary) to provide total scale scores. All scale scores were transformed to standard scores having a mean of 50 and a standard deviation of 20, so as to provide a common metric for comparing all results. Greater mean values reflect positive outcomes and scores less than 50 indicate relative impairment of recovery. The first behavioral change scale, “Psychological or Affect Changes After Heart Surgery”, contains six items pertaining to changes in feelings of depression, anxiety, pleasure in life and optimism, from one year prior to surgery to the present. The second behavioral change scale, “Social Adjustment Changes After Heart Surgery”, has ten items dealing with changes in relationships between patient and spouse, children, relatives and coworkers. The third scale, “Current Emotional State”, has eleven items pertaining to feelings during the past month of anxiety, nervousness, restlessness, sadness, happiness, contentment, the perception that psychological problems were interfering with recovery, and the patient’s use of tranquilizers and sleeping pills. The final nine-item scale, labeled “Current Social Network”, is based on current marital status, size of household, attendance at organizational meetings or religious services, perceived affection received from family members and family’s response during recovery (i.e. overprotection, adequate support, isolation or avoidance). The average correlations between each item and the sum of the remaining items in its scale for the four scales, respectively, were: 0.79, 0.67, 0.60 and 0.50.
RESULTS Between the time of initial surgery and response to the survey, an average of 3% years, these 949 patients experienced a variety of medical problems. These are summarized in Table 2. Hospitalization since surgery was reported by 51% of the patients. Over half of the patients (64%) were hospitalized for various cardiovascular problems, including arrhythmias. This includes the 12% of all persons who reported being hospitalized for heart attack. Thirteen per cent of all patients were admitted for gastrointestinal disorders and the remaining 23% were hospitalized for other difficulties. TABLE 2.-RATESOF
~ELE~TEDI~ED~~ALOUTCOMESBYSEXANDTYPEOFSURGERY
% with Sample second size surgery
% hospitalized since surgery
% with heart-related hospitalization
% with current severe and recurring pain or dyspnea
% reporting three or more days in bed last month
1 Vessel
Males Females
98 29
8 7
57 48
34 34
6 10
7 14
2 Vessels
Males Females
245 46
4 7
50 54
29 39
3 9
4 15
3 Vessels
Males Females
278 28
3 11
42 71
28 54
3 11
6 18
Mitral valve
Males Females
44 103
23 22
59 60
48 38
2 3
5 10
Aortic valve
Males Females
53 25
13 16
47 68
36 44
2 0
8 12
949
8
51
33
4
7
Total sample
A second major heart operation was sustained by 8% of all respondents. This rate varied greatly by the type of initial surgical procedure. Less than 5% of all bypass patients sustained second surgery, but 14% of aortic patients and 22% of mitral valve patients had a second surgical episode. This may have been influenced by the longer average period the valve patients had between surgery and follow-up study.
216
STEPHEN J.
ZYZANSKI,
BABETTE
A.
STANTON,
C. DAVID
JENKINS
and MICHAEL D. KLEIN
The percentages of persons experiencing severe and recurring symptoms of their heart condition in the past month and those requiring three or more days of bed rest in the past month are gratifyingly low, suggesting an excellent therapeutic result of surgery, on the average. Among bypass patients, a higher percentage of women than men reported severe recurring chest pain or dyspnea. For all types of surgery, women were confined to bed in the past month twice as frequently as men. Table 3 presents a series of analyses examining relationships between postoperative medical and postoperative psychosocial outcomes. Consistent decreases in psychosocial functioning were observed in patients experiencing postoperative heart-related hospitalization, other major (non-cardiac) health problems, continuing and intense chest pain and illness-related bed rest. TABLE
3.-AVERAGE
PSYCHOSOCIAL
Medical variables
OUTCOME
SCORES AS THEY
Response
(N)
Hospitalized post-operatively MI or valve problem Other heart problem Non-heart problem Not hospitalized
Yes Yes Yes Yes
101 214 172 462
Other major health problems (non-heart)
Yes No
253 696
More than 3 days sick in bed this month
Yes No
69 880
Continuing
Yes No
38 911
o-2 3-4 5-9 10+
338 330 213 64
intense chest pain
Years since surgery
Psychological change
RELATE
TO MEDICAL
Psychosocial Emotional status
41.1 45.5 52.0 53.3 t
ASPECTS
OF RECOVERY
outcomes Social adjustment
Social network
-
-
+
* = P< 0.05 (F-test). + = PCO.01. $ = P
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TABLE 4.-FACTORS AFFECTINGEMOTIONALCHANGESAFTER HEART SURGERY (standard scores (mean = 50) adjusted for 9 medical covariates) Sex Type of surgery
N
Male
Female
1 Vessel bypass 2 Vessel bypass 3 Vessel bypass Mitral valve Aortic valve
127 291 306 147 78
51.5 50.9 48.5 49.0 48.1
52.5 44.6 39.1 53.4 59.8
Forced retirement
Forced.to Not forced, but not working retire (N= 109) (N= 50)
(Limited to persons under 61 years)
44.7
Type A Behavior
type
(N=351)
47.4 Intermediate (N = 296)
Currently working (N=380)
51.9
F
P
6.9
0.001
Type B (N= 302) 53.0
48.8
48.4
Interaction: F= 4.0 P < 0.003 d.f. =4
F ’ 5.0
P 0.007
TABLE 5.-FACTORS AFFECTING SOCIAL ADJUSTMENT CHANGES AFTER HEART SURGERY(standard scores (mean = 50) adjusted for 9 medical covariates) Sex Level of education Some H.S. or less H.S. grad or added training Some college College grad or post-grad
Forced retirement (Limited to persons under 61 years)
N
Male
Female
138
51.3
56.5
357 254
51.2 48.3
47.2 53.4
200
47.9
52.1
Forced to Not forced, retire but not working (N= 109) (N= 50)
44.1
48.4
Currently working (N=380)
52.0
Interaction: F=2.7 P=O.O5 d.f. = 3 Main effects Education: N.S. Sex: N.S.
F
P
10.7
0.001
type of surgery, forced retirement, and Type A behavior pattern) remained significantly associated with the outcome scale score after nine medical covariates were statistically controlled. The medical covariates are: (1) number of surgical procedures performed at the initial surgery; (2) current age; (3) time since surgery; (4) rehospitalization since surgery; (5) heart-related hospitalizations (e.g. MI and CHF); (6) second heart surgery; (7) presence of continuing health problems not related to the heart; (8) current severe and recurring pain, and (9) having spent three or more days sick in bed in the past month. The search for predictors of postsurgical changes in emotional adjustment is summarized in Table 4. Changes in levels of anxiety, depression and general emotional state after heart surgery were significantly related to sex, type of surgery, forced retirement and coronary-prone behavior pattern. The significant “sex by type of surgery” interaction indicates that female multiple bypass patients, more than male bypass or female valve surgery patients, were likely to report that emotionally they felt worse now than they did one year prior to surgery. Patients who were clearly Type A personalities or intermediate in behavior type also experienced significantly more negative emotional changes than those categorized as Type B.
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STEPHENJ. ZYZANSKI, BABETTEA. STANTON,C. DAVID JENKINSand MICHAELD. KLEIN
For the “forced retirement” variable, statistical analysis was limited to those patients 60 years of age or younger to permit an adequate time period for returning to work which would not overlap with usual retirement ages. The results shown in Table 4 indicate that persons forced to retire experienced significantly more negative emotional changes subsequently than either persons currently working or those not working, but not forced to retire. Some factors affecting social adjustment changes after heart surgery are shown in Table 5. The patients experiencing the most negative changes in personal relationships with spouse, family and coworkers were persons of either sex reporting forced retirement, female high school graduates, and males with college education. Despite the clinical expectation that valve and bypass patients would differ in postoperative social adjustment changes, analysis of the data showed this not to be the case. A multivariate analysis (not presented in a table) revealed that behavior type and forced retirement remained significant correlates of current emotional status after adjustment for the medical co-variates. Persons classified as Type A personalities reported significantly more feelings of anxiety, depression, discouragement and restlessness in the past month (mean standard score = 46.2) than persons classified as Type B (mean score = 53.2, significance of difference, P = 0.001). Their current outlook, on the average, seems to be one of frustration and unrealized expectations. The final analysis revealed the strong effects of forced retirement on postoperative outcomes, in this case, present emotional status. Those currently working were relatively happy and cited the fewest psychological problems (mean standard score = 51.5). Those not working for reasons other than forced retirement were almost equal to the currently employed in their emotional status (mean = 50.3). Those forced into early retirement, however, reported that significant emotional difficulties were interfering with their recovery (mean = 47.7, significance of difference, P = 0.008). Thus, forced retirement seems to be related to negative changes in emotional and social adjustment, and to the emotional adjustment of patients by an average of 3% years postoperatively. Whether some of these negative changes might have preceded rather than followed the forced retirement cannot be determined from this retrospective design. Low scores on the scale, “Current Social Network”, represent deficits in psychosocial supports, including living alone, lack of participation in community activities, family withdrawal and lack of affection. These deficits are most common in females (P = O.Ol), Type A persons (P = 0.03), and those with lower levels of education (P = 0.02).
DISCUSSION
This study represents a preliminary effort to identify the various facets of postoperative recovery which are important to patients, and to their physicians, families and communities. We have developed sets of survey questions to elicit patients’ experiences of physical and psychological symptoms, interpersonal relationships, occupational activity and adjustment, financial situation, and other issues of adjustment deemed important by our consultant panel of heart surgery patients. While these methods still need refinement, we believe that this work represents progress in broadening the operational definition of recovery far beyond the traditional criteria of survival and unstructured questioning about relief from pain. The items appeared to be well comprehended by this large population of people from many backgrounds, as judged by the logical consistency of responses which our data editing revealed. The items and developed scales also had good distributional properties. Survey methodology of this sort seems to be a practical and quite reliable approach to defining and estimating the various socially relevant facts of recovery in large study populations. To what degree do the findings here reported adequately estimate the experience of the total population of survivors of these types of heart surgery? There is no existing enumeration of this population, and hence, we could neither sample from it nor determine what differences might exist between it and the population we studied. The membership of Mended Hearts, Inc., might be unrepresentative of the total, but the degree of bias may not be as great as first suspected. The socioeconomic data suggest that compared to the general U.S. population in this age
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range, this organization’s membership has a higher education level (48% with at least some college education, and only 15% who did not complete high school) and higher presurgical occupational status (70% in Hollingshead Occupational ratings l-4). If major heart surgery is more readily available to middle and upper class persons, it is possible that the population of U.S. heart surgery patients may differ from the general population in the same direction. Most of these respondents came from cohorts of patients whose surgery was performed since 1970, and hence loss from the sample due to death since surgery seems acceptably low. In terms of the influence course of recovery has on entry into Mended Hearts, Inc., the impressions of the organization leaders and the authors are that persons with poor initial courses of recovery, particularly those with continuing severe disability, are less likely to join the organization. These sources of bias tend to be counterbalanced somewhat by the fact that persons who return quickly into full-time employment and to their established social activities often feel that they have no further need for a patient organization and drop out of membership. Respondents to this survey had belonged to Mended Hearts for an average of 2% years. Response did not seem to be determined by level of activity in the organization, in that over a quarter never attended meetings, and another quarter attended only once or twice per year. These persons may not be dissimilar to former heart surgery patients who are not members of this organization. Thus it appears that the organizational membership lists represent a distribution of recovery outcomes truncated at the extremes, and perhaps thereby the mean level of recovery is not too seriously displaced from the true, but unknown population mean. Certain aspects of the sample lend encourgement as to its adequacy. The high response rate of 80%, achieved with only one reminder letter, suggests that the respondents are at least highly representative of this organization. It is also reassuring that the age-range and the proportions of men and women in our sample agree with other estimates of age-sex prevalences by type of surgery. Problems of recall of data were also taken into account by the time-frame of different types of questions. Softer items (those less objective and less well remembered), such as symptoms and perceptions, tended to be focused on the most recent month, except for some of the pre- vs. postsurgery comparison items. For harder data, such as hospitalizations, or occurrence of a heart attack, the time frame for recall was extended back to the date of heart surgery, a period of 4 years or less for 75% of the sample. In general, however, longer periods of recall are associated with the forgetting of events, and hence the reported frequencies of past medical complications are more likely to underestimate rather than overestimate their true prevalence. Nevertheless, despite these efforts to minimize systematic bias, caution in interpretation is warranted because these data are derived from patients’ self-reports of state of health in a retrospective study. We believe, however, that these data provide a relatively trustworthy basis for planning, at least until comprehensive prospective study data can be developed. A number of the findings deserve additional discussion. Inquiry regarding postoperative medical status revealed what seemed to be a rather high frequency of hospitalization-over 50% of persons had been hospitalized one or more times
220
STEPHEN J. ZYZANSKI, BABETTEA. STANTON, C. DAVID JENKINSand MICHAEL D. KLEIN
in the average elapsed time of 3 l/z years. Chronic gastrointestinal problems seemed particularly common. This finding deserves further investigation to see whether the array of orally administered drugs commonly prescribed for these patients may be contributing factors. The frequency of severe dyspnea and angina was gratifyingly low, suggesting a high rate of continuing effectiveness of the surgical correction. The findings that physical medical problems are correlated with poor psychosocial outcomes was expected. What was uncertain was whether additional indicators such as sex, type of surgery, level of education, forced retirement, or the Type A behavior pattern would be associated with psychosocial outcomes after the impact of physical medical problems had been accounted for. The direct relationship of these five variables to poor recovery outcomes is further supported by the fact that these predictors were also significant in the subgroup of patients who had none of the seven major postoperative physical health problems covered by the study. Forced retirement can cause a severe loss of self-esteem and self-acceptance and interfere with emotional adjustment in persons, such as Type A’s, for whom occupational role is central to self-concept. For many persons, employment provides more than just a livelihood. It also provides a social network and a variety of psychological gratifications. Focused study is needed to discover the reasons why women undergoing multiple bypass procedures tend to experience worse medical and psychological outcomes than men undergoing the same procedures or women having valve surgery. It may be that a substantial fraction of these women have either small vessel disease or cardiospasm, neither of which was corrected by surgery. The implications of these findings are several. Many aspects of these data indicate that heart surgery does not cause a permanent negative change in the social or psychological situation of most patients. On the contrary, of those with long-term changes from their preoperative levels, far more reported improvement than decline on all psychosocial indices studied, except for economic condition. Anecdotal reports point to excessive administrative difficulties and delays in obtaining disability payments and other federal and state benefits as contributing to the economic problems of some patients. Physical health problems and certain psychosocial factors contribute separately and independently to poor emotional state and poor social adjustment after surgery. It may also be that psychosocial factors contribute to physical health problems, but our study design and data analyses could not address this issue. The data suggest that efforts to prevent forced retirement after heart surgery might contribute substantially to improving overall recovery. The directionality of this relationship is suggested by the fact that persons forced to retire showed more problems than those not working for other reasons. The statistical control for postoperative medical problems supports the conclusion that the poor psychosocial recovery in those forced to retire was not attributable to their being physically sicker. Corporate policies and rehabilitative programs should be aimed at fostering return to work for heart surgery patients. This may sometimes require a change in the physical and emotional demands of the job. The finding regarding the poorer adjustment of Type A persons may in part derive from these persons having more severe atherosclerosis than Type B’s and hence more seriously compromised coronary vasculature [14]. In addition the
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impatient, striving, perfectionistic demands the Type A patient places upon himself tend to set the stage for disappointment and resentment over the pace of recovery. It might be useful to attempt patient education aimed at instilling realistic expectations regarding recovery, and individual counselling or group therapy to reduce intensity of the Type A pattern, and to deal with the episodes of anxiety, anger and depression to which the Type A persons seem, from these data, to be more susceptible. These intervention efforts should be evaluated both to see if they achieve their immediate therapeutic aims and if they improve the long-term psychosocial aspects of recovery. REFERENCES bypass grafting. Circulation 1. MCINTOSH H. D. and GARCIA J. A. The first decade of aortocoronary 57,405 (1978). responses to open-heart surgery. Nurs. Res. 21,220 (1972). 2. ELSBERRYN. L. Psychological to cardiac surgery. J. Thoruc. Surg. 58, 891 (1969). 3. KIMBALLC. P. A predictive study of adjustment 4. KIMBALL C. P. Psychological responses to the experience of open-heart surgery. Part 1. Am. J. Psychiat. 126,348 (1969). Psychosom. 5. TUFO H. M. and OSTFELD A. M. A prospective study of open-heart surgery (abstracted). Med. 30,552 (1968). adjustment and acute response 6. HENRICHS T. F., MCKINZIE J. W. and ALMOND C. H. Psychological to open-heart surgery. J. New. Ment. Dis. 148,158 (1969). 7. KILPATRICK D. G., MILLER W. C., ALLAIN A. N., HUGGINS M. B. and LEE JR. W. H. The use of psychological test data to predict open-heart surgery outcome: a prospective study. Psychosom. Med. 37,62 (1975). 8. BLACHLY P. H. and BLACHLY B. J. Vocational and emotional status of 263 patients after heart surgery. Circulation 38,524 (1968). 9. LUCIA W. and M&WIRE L. B. Rehabilitation and functional status after surgery for valvular heart disease. Archs Intern. Med. 126,995 (1970). 10. FRANK K. A., HELLER S. S. and KORNFELD D. S. A survey of adjustment to cardiac surgery. Archs Intern. Med. 130, 735 (1972). 11. HELLER S. D., FRANK K. A., KORNFELD D. S. and MALM JR., F. 0. Psychological outcome following open-heart surgery. Archs Intern. Med. 134,908 (1974). 12. GUNDLE M. J., BOZMAN R. R., TATE S., RAFT D. and MCLAURIN L. P. Psychosocial outcome of coronary artery surgery. Presented at the meeting of the American Psychiatric Association, Chicago, Illinois, 11-18 May, 1979. 13. JENKINS C. D., ZYZANSKI S. J. and ROSENMAN R. H. The Jenkins Activity Survey for Health Prediction. Boston, Massachusetts (1972). 14. ZYZANSKI S. _I., JENKINS C. D., RYAN T. .I., FLESSASA. and EVERIST M. Psychological correlates of coronary angiographic findings. Archs Intern. Med. 136, 1234 (1976).