- Email: [email protected]
Prevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training
technetium-99m-sestamibi SPECT include interpretation of attenuation artifacts as defects attributed to CAD, poor quality images in obese patients, and lower sensitivity in detecting mild stenoses of 50% to 70% in diameter compared with more severe lesions. Also, if patients are imaged while taking antianginal drugs, such as  blockers and nitrates, sensitivity may be diminished. The present study also sought to determine whether the degree of ST-segment depression corresponded to the frequency of perfusion abnormalities on technetium-99m-sestamibi SPECT in a population of patients with LV hypertrophy. Our results indicate that with similar levels of exercise, patients with a greater magnitude of ST depression do not have a corresponding higher frequency of abnormal perfusion defects compared with patients with lesser magnitudes of ST depression. Moreover, we found that many patients in the LV hypertrophy subpopulation exhibited ischemic electrocardiographic changes during exercise but no defects on perfusion imaging. Limitations of our study include its retrospective analysis, its specific patient population with LV hypertrophy, its high percentage of men, and the limitations of the electrocardiogram in diagnosing patients with LV hypertrophy. 1. Levy D, Labib SB, Anderson KM, Christiansen JC, Kannel WB, Castelli WP. Determinants of sensitivity and specificity of electrocardiographic criteria for left ventricular hypertrophy. Circulation 1990;81:815–820.
2. Smith WH, Kastner RJ, Calnon DA, Segalla D, Beller GA, Watson DD. Quantitative gated single photo emission computed tomography imaging: a counts-based method for display and measurement of regional and global ventricular systolic function. J Nucl Cardiol 1997;4:451–463. 3. Marzullo P, Sambuceti G, Parodi O. The role of sestamibi scintigraphy in the radioisotopic assessment of myocardial viability. J Nucl Med 1992;33:1925– 1930. 4. Kauffman GJ, Boyne TS, Watson DD, Smith WH, Beller GA. Comparison of rest thallium 201 imaging and rest technetium-99m sestamibi imaging for assessment of myocardial viability in patients with coronary artery disease and severe left ventricular dysfunction. J Am Coll Cardiol 199;27:1592–1597. 5. Smanio P, Watson DD, Segalla DL, Vinson EL, Smith WH, Beller GA. Value of gating of technetium-99m sestamibi single-photon emission computed tomographic imaging. J Am Coll Cardiol 1997;30:1687–1692. 6. Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987;106:793–800. 7. Mark DB, Shaw L, Harrell FE, Hlatky MA, Lee KL, Bengtson JR, McCants CB, Califf RM, Pryor DB. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325:849 – 853. 8. Froelicher VF, Thomas MM, Pillow C, Lancaster MC. Epidemiologic study of asymptomatic men screened by maximal treadmill testing for latent coronary artery disease. Am J Cardiol 1974;34:770 –776. 9. Massie BM, Szlachcic Y, Tubau JF, O’Kelly BF, Ammon S, Chin W. Scintigraphic and electrocardiographic evidence of silent coronary artery disease in asymptomatic hypertension: a case control study. J Am Coll Cardiol 1993;22: 1598 –1606. 10. Hlatky MA, Pryor DB, Harrell FE, Califf RM, Mark DB, Rosati RA. Factors affecting sensitivity and specificity of exercise electrocardiography. Am J Med 1984;77:64 –71. 11. Philbrick JT, Horowitz RI, Feinstein AR, Langou RA, Chandler JP. The limited spectrum of patients studied in exercise test research. JAMA 1982;248: 2467–2470. 12. Marwick TH, Torelli J, Harjai K, Haluska B, Pashkow F, Stewart W, Thomas JT. Influence of left ventricular hypertrophy on detection of coronary artery disease using exercise echocardiography. J Am Coll Cardiol 1995;26:1180 –1186. 13. Alshami A, Jolly S, Smith F, Reeves W, Movahed A. Exercise testing in patients with electrocardiographic evidence of left ventricular hypertrophy. Clin Nucl Med 1994;19:904 –909.
Prevalence of Anxiety in Coronary Patients With Improvement Following Cardiac Rehabilitation and Exercise Training Carl J. Lavie,
MD,
and Richard V. Milani,
Numerous studies have indicated that psychological distress, including anxiety, is a significant risk factor for coronary artery disease (CAD). We studied 500 consecutive patients after recent CAD events and demonstrated a very high prevalence of generalized anxiety and moderate to severe anxiety symptoms, particularly in younger patients. In addition, our data demonstrate the abnormal CAD risk profiles in these anxious patients with CAD and the marked improvements in the overall risk profiles, levels of anxiety, and overall quality of life after cardiac rehabilitation and exercise training programs. Greater attention at detecting and treating chronic anxiety, particularly From the Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Lousiana. Dr. Lavie’s address is: Department of Cardiology; Ochsner Clinic Foundation, 1514 Jefferson Highway; New Orleans, Lousiana 70121. E-mail: [email protected]. Manuscript received July 24, 2003; revised manuscript received and accepted October 2, 2003.
336
©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 February 1, 2004
MD
with formal cardiac rehabilitation, is needed for the secondary prevention of CAD. 䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:336 –339)
umerous studies indicate that psychological distress is a significant risk factor for coronary arN tery disease (CAD), which adversely affects recovery after major CAD events.1 Although most studies focus on depression and hostility,2– 6 acute and chronic anxiety also adversely affect cardiovascular risk.1,7–9 We and others have demonstrated the beneficial effects of cardiac rehabilitation and exercise training programs on improving exercise capacity, obesity indexes, plasma lipids, and behavioral characteristics, especially depression and hostility,2– 6 as well as reducing subsequent hospitalization costs and overall morbidity and mortality.10,11 To our knowledge, however, only limited information is available on the effects of this therapy in patients with CAD with high levels of anxiety. 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.10.015
ysis were performed as previously described.2– 6 Participants were referred to and participated in outpatient phase II cardiac rehabilitation, which consisted of 12 weeks and 36 educational and exercise sessions. Each session consisted of 10 minutes of warm-up exercise, including calisthenics and stretching, 30 to 40 minutes of continuous upright exercises (mostly treadmill and bicycling), and 10 minutes of cool-down calisthenics and stretching. Patients’ exercise recommendations were tailored toward the anaerobic threshFIGURE 1. Prevalence of anxiety (symptom score >7) and modold achieved during entry cardiopulmonary exercise erate to severe (high) anxiety symptoms (score >10) in various testing. Specific weight management guidance was age groups of patients with CAD. given to those subjects who were identified as overweight and obese. Patients and their spouses (or signifTABLE 1 Baseline Differences in Patients With High Anxiety Symptoms (symptom icant other) attended educational score ⬎10 U) Versus Patients Without Anxiety (symptom score ⱕ7 U) classes regarding all aspects of CAD High Anxiety Not Anxious risk, including hypertension, smokParameter (n ⫽ 66) (n ⫽ 367) p Value ing cessation, diabetes, and psychological distress, which were directed Age (yrs) 60 ⫾ 12 64 ⫾ 10 ⬍0.01 Weight (lbs) 193 ⫾ 43 178 ⫾ 35 ⬍0.05 by either a nurse trained in cardiac Percent body fat 27.2 ⫾ 7.4 25.9 ⫾ 8.2 ⬍0.05 rehabilitation, a licensed exercise 2 28.6 ⫾ 5.8 27.2 ⫾ 4.4 ⬍0.05 Body mass index (kg/m ) physiologist, or a registered dietiHigh-density lipoprotein cholesterol (mg/dl) 36.3 ⫾ 9.0 38.8 ⫾ 11.2 0.08 cian. During the lectures on psychoTriglycerides (mg/dl) 201 ⫾ 106 177 ⫾ 127 0.01 Low-density lipoprotein cholesterol/ 3.74 ⫾ 1.54 3.44 ⫾ 1.26 0.07 logical distress, the importance of High-density lipoprotein cholesterol psychological factors on the pathoTriglyceride/high-density lipoprotein 5.84 ⫾ 1.51 5.50 ⫾ 1.73 0.09 genesis and progression of CAD was cholesterol discussed, as well as potential ways Anxiety score (U) 15.3 ⫾ 2.7 2.2 ⫾ 2.2 ⬍0.0001 to reduce distress (exercise, meditaDepression score (U) 11.2 ⫾ 4.5 1.8 ⫾ 2.4 ⬍0.0001 Hostility score (U) 8.1 ⫾ 5.6 1.5 ⫾ 2.3 ⬍0.0001 tion, deep breathing exercises, visuSomatization score (U) 11.0 ⫾ 4.7 5.6 ⫾ 3.6 ⬍0.001 alization techniques, and medicaQuality-of-life score (U) 82 ⫾ 17 103 ⫾ 17 ⬍0.0001 tions), but more detailed therapies were not formally utilized and no extra attention was given to patients with adverse baseline behavioral characteristics. Com••• We studied 500 consecutive patients with CAD pliance with the supervised exercise program and edwho were referred to, attended, and completed phase ucational sessions was similar in patients with high II cardiac rehabilitation and exercise training pro- anxiety and patients without anxiety; patients were grams after a major CAD event (acute myocardial also encouraged to perform 1 to 3 exercise sessions infarction in 25%, coronary artery bypass grafting in per week at home, but compliance with the nonsuper40%, or percutaneous revascularization for an acute vised exercise was not systematically assessed. At baseline (2 to 8 weeks after the major CAD CAD syndrome in 35%—some patients had ⬎1 clinical event). All patients underwent assessment of be- event; average 4 to 5 weeks) and again within 1 week havioral characteristics using the Kellner symptom of completing the cardiac rehabilitation and exercise questionnaire,12,13 which has been validated for psy- program, we obtained several measurements: height, chological distress as well as patient components (de- weight, body mass index, percent body fat, plasma pression, hostility, somatization, and anxiety); a lower lipids, estimated METs, and questionnaires to assess score indicated a more favorable behavioral trait. We behavioral characteristics and overall quality of life. The results were expressed as mean ⫾ SD. For staalso used the Medical Outcomes Study Short Form 36 Survey to assess quality of life; a higher score indi- tistical analysis, we used chi-square, analysis of variance, cated a more favorable quality of life.14 We deter- and unpaired t tests to assess differences among patients mined the prevalence of anxiety symptoms (score ⬎7) without anxiety and with high levels of anxiety. Baseline and high anxiety symptoms (score ⬎10) in various and post-rehabilitation data were compared in both age groups (⬍55, 55 to 70, and ⬎70 years) and groups by paired t tests, and changes between groups analyzed the baseline characteristics between patients were analyzed by 2-factor (before and after rehabilitation with high anxiety and patients without anxiety as well and anxiety status) repeated measures analysis of varias the effects of cardiac rehabilitation and exercise ance and repeated measures in 1-factor (before and after training programs in these groups. Patients were not rehabilitation data). In addition, data in men and women taking daily antianxiety or antidepressant medications were evaluated separately. The prevalence of anxiety and high anxiety sympduring the study protocol, although the use of periodic toms were very high in the younger patients (⬍55 years) (as needed) medications was not assessed. The protocol, data collection, and statistical anal- and was considerably higher (p ⬍0.01) than the prevaBRIEF REPORTS
337
prevalence of anxiety (⫺56%) and high anxiety (⫺69%; Figure 2). Patients with high anxiety had marked improvements in obesity indexes (weight, percent fat, and body mass index), exercise capacity, lipids (HDL, total cholesterol/HDL ratio, and triglycerides/HDL ratio), and behavioral characteristics and overall quality of life (Table 2). The improvement in anxiety scores, prevalence of anxiety and high anxiety symptoms, and most CAD risk factors, including quality of life, were statistically similar in men and FIGURE 2. Prevalence of anxiety (symptom score >7) and high women. Although most of the improvements noted in anxiety symptoms (score >10) before and after cardiac rehabilipatients with high anxiety were statistically similar to tation and exercise training programs. improvements noted in those without anxiety, patients with high anxiety had statistically greater improveTABLE 2 Benefits of Cardiac Rehabilitation in Patients With High Levels of Anxiety ments in anxiety scores (⫺56% vs Symptoms (score ⬎10 U; n ⫽ 66) ⫺14%, p ⬍0.05), depression scores Before After (⫺56% vs ⫺17%, p ⬍0.05), and Parameter Rehabilitation Rehabilitation %⌬ p Value overall quality of life scores (⫹28% vs ⫹14%; p ⬍0.01) compared with Weight (lbs) 193 ⫾ 43 187 ⫾ 40 ⫺3% 0.02 Percent body fat 27.2 ⫾ 7.4 25.3 ⫾ 7.6 ⫺7% ⬍0.01 patients without anxiety. 2 Body mass index (kg/m ) Exercise capacity (estimated METs) Total cholesterol (mg/dl) Triglycerides (mg/dl) High-density lipoprotein cholesterol (mg/dl) Low-density lipoprotein cholesterol (mg/dl) Total cholesterol/high-density lipoprotein cholesterol Triglycerides/high-density lipoprotein cholesterol Anxiety score (U) Depression score (U) Somatization score (U) Hostility score (U) Quality-of-life score (U)
28.6 ⫾ 5.8 5.2 ⫾ 2.7
27.7 ⫾ 5.6 7.5 ⫾ 3.7
⫺3% ⫹44%
0.02 ⬍0.0001
•••
Although the importance of psychological distress in the pathogene204 ⫾ 39 199 ⫾ 43 ⫺2% 0.46 201 ⫾ 106 185 ⫾ 92 ⫺8% 0.11 sis and expression of CAD has been 36.3 ⫾ 9.0 38.3 ⫾ 10.1 ⫹6% 0.02 debated for years, considerable recent literature has established the im131 ⫾ 57 124 ⫾ 36 ⫺5% 0.32 portance of various psychological factors in CAD.1– 6 Although most of 5.84 ⫾ 1.51 5.46 ⫾ 1.54 ⫺7% ⬍0.05 this evidence has focused on depres5.84 ⫾ 1.51 5.46 ⫾ 1.54 ⫺7% ⬍0.05 sion and hostility, increasing evidence has now linked anxiety disor15.3 ⫾ 2.7 6.7 ⫾ 5.9 ⫺56% ⬍0.0001 ders to the development of cardiac 11.2 ⫾ 4.5 6.7 ⫾ 5.9 ⫺56% ⬍0.0001 11.0 ⫾ 4.7 6.3 ⫾ 4.1 ⫺43% ⬍0.0001 events.1,7–9 Our results demonstrate 8.1 ⫾ 5.6 4.1 ⫾ 4.7 ⫺19% ⬍0.0001 the high prevalence of anxiety symp82 ⫾ 17 104 ⫾ 16 ⫹28% ⬍0.0001 toms in patients with CAD, the abnormal CAD risk profiles present in the more anxious patients with CAD, lence rates in the older groups of patients (Figure 1). and the significant benefits that occur after formal Although women were slightly older (65 ⫾ 10 vs 62 ⫾ cardiac rehabilitation and exercise programs, includ11 years; p ⬍0.01), the prevalence of anxiety (26% vs ing improvements in the overall CAD risk profile, as 27%) and high anxiety symptoms (13% vs 14%), how- well as marked reductions in anxiety. Although the role of anxiety in CAD has been ever, were statistically similar in men and women, and both genders had statistically similar anxiety scores (4.8 somewhat controversial, and several studies have not ⫾ 5.0 vs 5.4 ⫾ 5.6 U; p ⫽ 0.28). Besides being, on demonstrated a significant relation between anxiety average, 4 years younger, patients with high anxiety and myocardial infarction, several large-scale commudiffered considerably from those without anxiety (Table nity-based studies have demonstrated a significant reand cardiac death, especially 1), including having significantly higher weight, percent lation between anxiety1,7–9 sudden cardiac death. A dose-dependent relation body fat, body mass indexes, triglycerides, and trends for has been noted between overall levels of anxiety and higher low-density lipoprotein (LDL)/high-density lisudden cardiac death.1,8,9 poprotein (HDL) ratios and triglyceride/HDL ratios, as Because anxiety seems to be more related to sudwell as lower HDL levels. Besides having higher levels den cardiac death versus myocardial infarction, this of anxiety by design, these patients with high anxiety suggests that malignant ventricular arrhythmias due to also had considerably higher scores for depression, hos- increased sympathetic stimulation or impaired vagal tility, and somatization, and 20% lower quality of life tone may be involved with increased cardiac mortalscores. Both groups were statistically similar with regard ity.1,15 Although we did not assess the effects of to gender (76% and 80% were men in the high anxiety cardiac rehabilitation and exercise training on ventricgroup and the group without anxiety, respectively) and ular ectopic activity or vagal tone in the present study, baseline exercise capacity. we have previously demonstrated the benefits of carAfter the cardiac rehabilitation and exercise train- diac rehabilitation to improve indexes of ventricular ing programs, there were significant reductions in the repolarization dispersion16,17 and to improve auto338 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 93
FEBRUARY 1, 2004
nomic function,18 which may be particularly applicable to patients with CAD who have high anxiety. A few study limitations should be emphasized. Our study was nonrandomized, and there was no control group. At our institution, ⬎90% patients with CAD events are referred to cardiac rehabilitation, and we have previously demonstrated similar behavioral characteristics in ⬎200 patients with CAD who initially attended, but who did not complete cardiac rehabilitation.6 In addition, we have recently studied 42 “control” subjects who chose not to attend rehabilitation; we did not note any significant improvements over time in their overall CAD profiles.19 In another group of 20 patients who were candidates for cardiac rehabilitation but who did not attend, there were no significant changes over time in behavioral characteristics, including anxiety scores.6 1. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999;99:2192–2217. 2. Milani RV, Lavie CJ, Cassidy MM. Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events. Am Heart J 1996;132:726 –732. 3. Milani RV, Lavie CJ. Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events. Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events. Am J Med 1996;100:517–523. 4. Milani RV, Lavie CJ. Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. Am J Cardiol 1998;81: 1233–1236. 5. Lavie CJ, Milani RV, Cassidy MM, Gilliland YE. Effects of cardiac rehabil-
itation and exercise training programs in women with depression. Am J Cardiol 1999;83:1480 –1483. 6. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility. Mayo Clin Proc 1999;74:959 –966. 7. Haines AP, Imeson JD, Meade TW. Phobic anxiety and ischaemic heart disease. BMJ 1987;295:297–299. 8. Kawachi I, Colditz GA, Ascherio A, Rimm EB, Giovannucci E, Stampfer MJ, Willett WC. Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation 1994;89:1992–1997. 9. Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation 1994;90: 2225–2229. 10. Ades PA, Huang D, Weaver SO. Cardiac rehabilitation participation predicts lower rehospitalization costs. Am Heart J 1992;123:916 –921. 11. O’Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS Jr., Hennekens CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989;80:234 –244. 12. Kellner R. A symptom questionnaire. J Clin Psychiatry 1987;48:268 –274. 13. Kellner R, Sheffield BF. A self-rating scale of distress. Psycholo Med 1973;3:88 –100. 14. Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, McGlynn EA, Ware JE Jr. Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. JAMA 1989;262: 907–913. 15. Curtis BM, O’Keefe JH Jr. Autonomic tone as a cardiovascular risk factor: the dangers of chronic fight or flight. Mayo Clin Proc 2002;77:45–54. 16. Ali A, Mehra MR, Malik FS, Lavie CJ, Bass D, Milani RV. Effects of aerobic exercise training on indices of ventricular repolarization in patients with chronic heart failure. Chest 1999;116:83–87. 17. Kalapura T, Lavie CJ, Jaffrani W, Chilakamarri V, Milani RV. Effects of cardiac rehabilitation and exercise training on indexes of dispersion of ventricular repolarization in patients after acute myocardial infarction. Am J Cardiol 2003; 92:292–294. 18. Lucini D, Milani RV, Costantino G, Lavie CJ, Porta A, Pagani M. Effects of cardiac rehabilitation and exercise training on autonomic regulation in patients with coronary artery disease. Am Heart J 2002;143:977–983. 19. Milani RV, Lavie CJ. Prevalence and profile of metabolic syndrome in patients following acute coronary events and effects of therapeutic lifestyle change with cardiac rehabilitation. Am J Cardiol 2003;92:50 –54.
Effect of Preintervention Remodeling Type on Subsequent Coronary Artery Behavior After Directional Atherectomy Yoshihiro Takeda, MD, Etsuo Tsuchikane, MD, Tomoko Kobayashi, MD, Kenji Yachiku, MD, Kenya Nasu, MD, Nobuhisa Awata, MD, and Tohru Kobayashi, To evaluate the influence of preintervention remodeling on subsequent vessel behavior after directional coronary atherectomy (DCA) under intravascular ultrasound (IVUS) guidance, serial (before and after DCA and at 6-month follow-up) IVUS data were analyzed for 246 lesions that were classified into 2 categories: positive remodeling (PR) in 77 lesions versus intermediate or negative remodeling in 169 lesions. Although the 2 groups had similar baseline characteristics, IVUS data showed that the PR group had a greater acute lumen area (LA) gain without an increased late LA loss, resulting in a greater net (acute From the Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan. Dr. Takeda’s address is: Department of Cardiology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinariku, Osaka City, Osaka 5378511, Japan. E-mail: [email protected]. Manuscript received July 25, 2003; revised manuscript received and accepted October 7, 2003. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 February 1, 2004
MD
plus late) LA gain and follow-up LA. This suggests that IVUS-guided DCA may neutralize the negative impact of preintervention PR on late vessel patency. 䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:339 –343)
ecent intravascular (IVUS) studies have suggested that preintervention positive remodeling R (PR) associated with a large plaque burden represents 1– 6
a biologically active disease state that may not be particularly well suited for coronary interventions, including stenting. After IVUS-guided directional coronary atherectomy (DCA), we examined serial (before and after DCA and at 6-month follow-up) IVUS data to determine the impact of differences in preintervention remodeling on subsequent vessel change. •••
Criteria for lesion inclusion comprised de novo native coronary artery disease treated with IVUSguided DCA with complete serial (before and after 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.10.016
339
2. Smith WH, Kastner RJ, Calnon DA, Segalla D, Beller GA, Watson DD. Quantitative gated single photo emission computed tomography imaging: a counts-based method for display and measurement of regional and global ventricular systolic function. J Nucl Cardiol 1997;4:451–463. 3. Marzullo P, Sambuceti G, Parodi O. The role of sestamibi scintigraphy in the radioisotopic assessment of myocardial viability. J Nucl Med 1992;33:1925– 1930. 4. Kauffman GJ, Boyne TS, Watson DD, Smith WH, Beller GA. Comparison of rest thallium 201 imaging and rest technetium-99m sestamibi imaging for assessment of myocardial viability in patients with coronary artery disease and severe left ventricular dysfunction. J Am Coll Cardiol 199;27:1592–1597. 5. Smanio P, Watson DD, Segalla DL, Vinson EL, Smith WH, Beller GA. Value of gating of technetium-99m sestamibi single-photon emission computed tomographic imaging. J Am Coll Cardiol 1997;30:1687–1692. 6. Mark DB, Hlatky MA, Harrell FE, Lee KL, Califf RM, Pryor DB. Exercise treadmill score for predicting prognosis in coronary artery disease. Ann Intern Med 1987;106:793–800. 7. Mark DB, Shaw L, Harrell FE, Hlatky MA, Lee KL, Bengtson JR, McCants CB, Califf RM, Pryor DB. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991;325:849 – 853. 8. Froelicher VF, Thomas MM, Pillow C, Lancaster MC. Epidemiologic study of asymptomatic men screened by maximal treadmill testing for latent coronary artery disease. Am J Cardiol 1974;34:770 –776. 9. Massie BM, Szlachcic Y, Tubau JF, O’Kelly BF, Ammon S, Chin W. Scintigraphic and electrocardiographic evidence of silent coronary artery disease in asymptomatic hypertension: a case control study. J Am Coll Cardiol 1993;22: 1598 –1606. 10. Hlatky MA, Pryor DB, Harrell FE, Califf RM, Mark DB, Rosati RA. Factors affecting sensitivity and specificity of exercise electrocardiography. Am J Med 1984;77:64 –71. 11. Philbrick JT, Horowitz RI, Feinstein AR, Langou RA, Chandler JP. The limited spectrum of patients studied in exercise test research. JAMA 1982;248: 2467–2470. 12. Marwick TH, Torelli J, Harjai K, Haluska B, Pashkow F, Stewart W, Thomas JT. Influence of left ventricular hypertrophy on detection of coronary artery disease using exercise echocardiography. J Am Coll Cardiol 1995;26:1180 –1186. 13. Alshami A, Jolly S, Smith F, Reeves W, Movahed A. Exercise testing in patients with electrocardiographic evidence of left ventricular hypertrophy. Clin Nucl Med 1994;19:904 –909.
Prevalence of Anxiety in Coronary Patients With Improvement Following Cardiac Rehabilitation and Exercise Training Carl J. Lavie,
MD,
and Richard V. Milani,
Numerous studies have indicated that psychological distress, including anxiety, is a significant risk factor for coronary artery disease (CAD). We studied 500 consecutive patients after recent CAD events and demonstrated a very high prevalence of generalized anxiety and moderate to severe anxiety symptoms, particularly in younger patients. In addition, our data demonstrate the abnormal CAD risk profiles in these anxious patients with CAD and the marked improvements in the overall risk profiles, levels of anxiety, and overall quality of life after cardiac rehabilitation and exercise training programs. Greater attention at detecting and treating chronic anxiety, particularly From the Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Lousiana. Dr. Lavie’s address is: Department of Cardiology; Ochsner Clinic Foundation, 1514 Jefferson Highway; New Orleans, Lousiana 70121. E-mail: [email protected]. Manuscript received July 24, 2003; revised manuscript received and accepted October 2, 2003.
336
©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 February 1, 2004
MD
with formal cardiac rehabilitation, is needed for the secondary prevention of CAD. 䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:336 –339)
umerous studies indicate that psychological distress is a significant risk factor for coronary arN tery disease (CAD), which adversely affects recovery after major CAD events.1 Although most studies focus on depression and hostility,2– 6 acute and chronic anxiety also adversely affect cardiovascular risk.1,7–9 We and others have demonstrated the beneficial effects of cardiac rehabilitation and exercise training programs on improving exercise capacity, obesity indexes, plasma lipids, and behavioral characteristics, especially depression and hostility,2– 6 as well as reducing subsequent hospitalization costs and overall morbidity and mortality.10,11 To our knowledge, however, only limited information is available on the effects of this therapy in patients with CAD with high levels of anxiety. 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.10.015
ysis were performed as previously described.2– 6 Participants were referred to and participated in outpatient phase II cardiac rehabilitation, which consisted of 12 weeks and 36 educational and exercise sessions. Each session consisted of 10 minutes of warm-up exercise, including calisthenics and stretching, 30 to 40 minutes of continuous upright exercises (mostly treadmill and bicycling), and 10 minutes of cool-down calisthenics and stretching. Patients’ exercise recommendations were tailored toward the anaerobic threshFIGURE 1. Prevalence of anxiety (symptom score >7) and modold achieved during entry cardiopulmonary exercise erate to severe (high) anxiety symptoms (score >10) in various testing. Specific weight management guidance was age groups of patients with CAD. given to those subjects who were identified as overweight and obese. Patients and their spouses (or signifTABLE 1 Baseline Differences in Patients With High Anxiety Symptoms (symptom icant other) attended educational score ⬎10 U) Versus Patients Without Anxiety (symptom score ⱕ7 U) classes regarding all aspects of CAD High Anxiety Not Anxious risk, including hypertension, smokParameter (n ⫽ 66) (n ⫽ 367) p Value ing cessation, diabetes, and psychological distress, which were directed Age (yrs) 60 ⫾ 12 64 ⫾ 10 ⬍0.01 Weight (lbs) 193 ⫾ 43 178 ⫾ 35 ⬍0.05 by either a nurse trained in cardiac Percent body fat 27.2 ⫾ 7.4 25.9 ⫾ 8.2 ⬍0.05 rehabilitation, a licensed exercise 2 28.6 ⫾ 5.8 27.2 ⫾ 4.4 ⬍0.05 Body mass index (kg/m ) physiologist, or a registered dietiHigh-density lipoprotein cholesterol (mg/dl) 36.3 ⫾ 9.0 38.8 ⫾ 11.2 0.08 cian. During the lectures on psychoTriglycerides (mg/dl) 201 ⫾ 106 177 ⫾ 127 0.01 Low-density lipoprotein cholesterol/ 3.74 ⫾ 1.54 3.44 ⫾ 1.26 0.07 logical distress, the importance of High-density lipoprotein cholesterol psychological factors on the pathoTriglyceride/high-density lipoprotein 5.84 ⫾ 1.51 5.50 ⫾ 1.73 0.09 genesis and progression of CAD was cholesterol discussed, as well as potential ways Anxiety score (U) 15.3 ⫾ 2.7 2.2 ⫾ 2.2 ⬍0.0001 to reduce distress (exercise, meditaDepression score (U) 11.2 ⫾ 4.5 1.8 ⫾ 2.4 ⬍0.0001 Hostility score (U) 8.1 ⫾ 5.6 1.5 ⫾ 2.3 ⬍0.0001 tion, deep breathing exercises, visuSomatization score (U) 11.0 ⫾ 4.7 5.6 ⫾ 3.6 ⬍0.001 alization techniques, and medicaQuality-of-life score (U) 82 ⫾ 17 103 ⫾ 17 ⬍0.0001 tions), but more detailed therapies were not formally utilized and no extra attention was given to patients with adverse baseline behavioral characteristics. Com••• We studied 500 consecutive patients with CAD pliance with the supervised exercise program and edwho were referred to, attended, and completed phase ucational sessions was similar in patients with high II cardiac rehabilitation and exercise training pro- anxiety and patients without anxiety; patients were grams after a major CAD event (acute myocardial also encouraged to perform 1 to 3 exercise sessions infarction in 25%, coronary artery bypass grafting in per week at home, but compliance with the nonsuper40%, or percutaneous revascularization for an acute vised exercise was not systematically assessed. At baseline (2 to 8 weeks after the major CAD CAD syndrome in 35%—some patients had ⬎1 clinical event). All patients underwent assessment of be- event; average 4 to 5 weeks) and again within 1 week havioral characteristics using the Kellner symptom of completing the cardiac rehabilitation and exercise questionnaire,12,13 which has been validated for psy- program, we obtained several measurements: height, chological distress as well as patient components (de- weight, body mass index, percent body fat, plasma pression, hostility, somatization, and anxiety); a lower lipids, estimated METs, and questionnaires to assess score indicated a more favorable behavioral trait. We behavioral characteristics and overall quality of life. The results were expressed as mean ⫾ SD. For staalso used the Medical Outcomes Study Short Form 36 Survey to assess quality of life; a higher score indi- tistical analysis, we used chi-square, analysis of variance, cated a more favorable quality of life.14 We deter- and unpaired t tests to assess differences among patients mined the prevalence of anxiety symptoms (score ⬎7) without anxiety and with high levels of anxiety. Baseline and high anxiety symptoms (score ⬎10) in various and post-rehabilitation data were compared in both age groups (⬍55, 55 to 70, and ⬎70 years) and groups by paired t tests, and changes between groups analyzed the baseline characteristics between patients were analyzed by 2-factor (before and after rehabilitation with high anxiety and patients without anxiety as well and anxiety status) repeated measures analysis of varias the effects of cardiac rehabilitation and exercise ance and repeated measures in 1-factor (before and after training programs in these groups. Patients were not rehabilitation data). In addition, data in men and women taking daily antianxiety or antidepressant medications were evaluated separately. The prevalence of anxiety and high anxiety sympduring the study protocol, although the use of periodic toms were very high in the younger patients (⬍55 years) (as needed) medications was not assessed. The protocol, data collection, and statistical anal- and was considerably higher (p ⬍0.01) than the prevaBRIEF REPORTS
337
prevalence of anxiety (⫺56%) and high anxiety (⫺69%; Figure 2). Patients with high anxiety had marked improvements in obesity indexes (weight, percent fat, and body mass index), exercise capacity, lipids (HDL, total cholesterol/HDL ratio, and triglycerides/HDL ratio), and behavioral characteristics and overall quality of life (Table 2). The improvement in anxiety scores, prevalence of anxiety and high anxiety symptoms, and most CAD risk factors, including quality of life, were statistically similar in men and FIGURE 2. Prevalence of anxiety (symptom score >7) and high women. Although most of the improvements noted in anxiety symptoms (score >10) before and after cardiac rehabilipatients with high anxiety were statistically similar to tation and exercise training programs. improvements noted in those without anxiety, patients with high anxiety had statistically greater improveTABLE 2 Benefits of Cardiac Rehabilitation in Patients With High Levels of Anxiety ments in anxiety scores (⫺56% vs Symptoms (score ⬎10 U; n ⫽ 66) ⫺14%, p ⬍0.05), depression scores Before After (⫺56% vs ⫺17%, p ⬍0.05), and Parameter Rehabilitation Rehabilitation %⌬ p Value overall quality of life scores (⫹28% vs ⫹14%; p ⬍0.01) compared with Weight (lbs) 193 ⫾ 43 187 ⫾ 40 ⫺3% 0.02 Percent body fat 27.2 ⫾ 7.4 25.3 ⫾ 7.6 ⫺7% ⬍0.01 patients without anxiety. 2 Body mass index (kg/m ) Exercise capacity (estimated METs) Total cholesterol (mg/dl) Triglycerides (mg/dl) High-density lipoprotein cholesterol (mg/dl) Low-density lipoprotein cholesterol (mg/dl) Total cholesterol/high-density lipoprotein cholesterol Triglycerides/high-density lipoprotein cholesterol Anxiety score (U) Depression score (U) Somatization score (U) Hostility score (U) Quality-of-life score (U)
28.6 ⫾ 5.8 5.2 ⫾ 2.7
27.7 ⫾ 5.6 7.5 ⫾ 3.7
⫺3% ⫹44%
0.02 ⬍0.0001
•••
Although the importance of psychological distress in the pathogene204 ⫾ 39 199 ⫾ 43 ⫺2% 0.46 201 ⫾ 106 185 ⫾ 92 ⫺8% 0.11 sis and expression of CAD has been 36.3 ⫾ 9.0 38.3 ⫾ 10.1 ⫹6% 0.02 debated for years, considerable recent literature has established the im131 ⫾ 57 124 ⫾ 36 ⫺5% 0.32 portance of various psychological factors in CAD.1– 6 Although most of 5.84 ⫾ 1.51 5.46 ⫾ 1.54 ⫺7% ⬍0.05 this evidence has focused on depres5.84 ⫾ 1.51 5.46 ⫾ 1.54 ⫺7% ⬍0.05 sion and hostility, increasing evidence has now linked anxiety disor15.3 ⫾ 2.7 6.7 ⫾ 5.9 ⫺56% ⬍0.0001 ders to the development of cardiac 11.2 ⫾ 4.5 6.7 ⫾ 5.9 ⫺56% ⬍0.0001 11.0 ⫾ 4.7 6.3 ⫾ 4.1 ⫺43% ⬍0.0001 events.1,7–9 Our results demonstrate 8.1 ⫾ 5.6 4.1 ⫾ 4.7 ⫺19% ⬍0.0001 the high prevalence of anxiety symp82 ⫾ 17 104 ⫾ 16 ⫹28% ⬍0.0001 toms in patients with CAD, the abnormal CAD risk profiles present in the more anxious patients with CAD, lence rates in the older groups of patients (Figure 1). and the significant benefits that occur after formal Although women were slightly older (65 ⫾ 10 vs 62 ⫾ cardiac rehabilitation and exercise programs, includ11 years; p ⬍0.01), the prevalence of anxiety (26% vs ing improvements in the overall CAD risk profile, as 27%) and high anxiety symptoms (13% vs 14%), how- well as marked reductions in anxiety. Although the role of anxiety in CAD has been ever, were statistically similar in men and women, and both genders had statistically similar anxiety scores (4.8 somewhat controversial, and several studies have not ⫾ 5.0 vs 5.4 ⫾ 5.6 U; p ⫽ 0.28). Besides being, on demonstrated a significant relation between anxiety average, 4 years younger, patients with high anxiety and myocardial infarction, several large-scale commudiffered considerably from those without anxiety (Table nity-based studies have demonstrated a significant reand cardiac death, especially 1), including having significantly higher weight, percent lation between anxiety1,7–9 sudden cardiac death. A dose-dependent relation body fat, body mass indexes, triglycerides, and trends for has been noted between overall levels of anxiety and higher low-density lipoprotein (LDL)/high-density lisudden cardiac death.1,8,9 poprotein (HDL) ratios and triglyceride/HDL ratios, as Because anxiety seems to be more related to sudwell as lower HDL levels. Besides having higher levels den cardiac death versus myocardial infarction, this of anxiety by design, these patients with high anxiety suggests that malignant ventricular arrhythmias due to also had considerably higher scores for depression, hos- increased sympathetic stimulation or impaired vagal tility, and somatization, and 20% lower quality of life tone may be involved with increased cardiac mortalscores. Both groups were statistically similar with regard ity.1,15 Although we did not assess the effects of to gender (76% and 80% were men in the high anxiety cardiac rehabilitation and exercise training on ventricgroup and the group without anxiety, respectively) and ular ectopic activity or vagal tone in the present study, baseline exercise capacity. we have previously demonstrated the benefits of carAfter the cardiac rehabilitation and exercise train- diac rehabilitation to improve indexes of ventricular ing programs, there were significant reductions in the repolarization dispersion16,17 and to improve auto338 THE AMERICAN JOURNAL OF CARDIOLOGY姞
VOL. 93
FEBRUARY 1, 2004
nomic function,18 which may be particularly applicable to patients with CAD who have high anxiety. A few study limitations should be emphasized. Our study was nonrandomized, and there was no control group. At our institution, ⬎90% patients with CAD events are referred to cardiac rehabilitation, and we have previously demonstrated similar behavioral characteristics in ⬎200 patients with CAD who initially attended, but who did not complete cardiac rehabilitation.6 In addition, we have recently studied 42 “control” subjects who chose not to attend rehabilitation; we did not note any significant improvements over time in their overall CAD profiles.19 In another group of 20 patients who were candidates for cardiac rehabilitation but who did not attend, there were no significant changes over time in behavioral characteristics, including anxiety scores.6 1. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 1999;99:2192–2217. 2. Milani RV, Lavie CJ, Cassidy MM. Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events. Am Heart J 1996;132:726 –732. 3. Milani RV, Lavie CJ. Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events. Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events. Am J Med 1996;100:517–523. 4. Milani RV, Lavie CJ. Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. Am J Cardiol 1998;81: 1233–1236. 5. Lavie CJ, Milani RV, Cassidy MM, Gilliland YE. Effects of cardiac rehabil-
itation and exercise training programs in women with depression. Am J Cardiol 1999;83:1480 –1483. 6. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility. Mayo Clin Proc 1999;74:959 –966. 7. Haines AP, Imeson JD, Meade TW. Phobic anxiety and ischaemic heart disease. BMJ 1987;295:297–299. 8. Kawachi I, Colditz GA, Ascherio A, Rimm EB, Giovannucci E, Stampfer MJ, Willett WC. Prospective study of phobic anxiety and risk of coronary heart disease in men. Circulation 1994;89:1992–1997. 9. Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease. The Normative Aging Study. Circulation 1994;90: 2225–2229. 10. Ades PA, Huang D, Weaver SO. Cardiac rehabilitation participation predicts lower rehospitalization costs. Am Heart J 1992;123:916 –921. 11. O’Connor GT, Buring JE, Yusuf S, Goldhaber SZ, Olmstead EM, Paffenbarger RS Jr., Hennekens CH. An overview of randomized trials of rehabilitation with exercise after myocardial infarction. Circulation 1989;80:234 –244. 12. Kellner R. A symptom questionnaire. J Clin Psychiatry 1987;48:268 –274. 13. Kellner R, Sheffield BF. A self-rating scale of distress. Psycholo Med 1973;3:88 –100. 14. Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry SD, McGlynn EA, Ware JE Jr. Functional status and well-being of patients with chronic conditions. Results from the Medical Outcomes Study. JAMA 1989;262: 907–913. 15. Curtis BM, O’Keefe JH Jr. Autonomic tone as a cardiovascular risk factor: the dangers of chronic fight or flight. Mayo Clin Proc 2002;77:45–54. 16. Ali A, Mehra MR, Malik FS, Lavie CJ, Bass D, Milani RV. Effects of aerobic exercise training on indices of ventricular repolarization in patients with chronic heart failure. Chest 1999;116:83–87. 17. Kalapura T, Lavie CJ, Jaffrani W, Chilakamarri V, Milani RV. Effects of cardiac rehabilitation and exercise training on indexes of dispersion of ventricular repolarization in patients after acute myocardial infarction. Am J Cardiol 2003; 92:292–294. 18. Lucini D, Milani RV, Costantino G, Lavie CJ, Porta A, Pagani M. Effects of cardiac rehabilitation and exercise training on autonomic regulation in patients with coronary artery disease. Am Heart J 2002;143:977–983. 19. Milani RV, Lavie CJ. Prevalence and profile of metabolic syndrome in patients following acute coronary events and effects of therapeutic lifestyle change with cardiac rehabilitation. Am J Cardiol 2003;92:50 –54.
Effect of Preintervention Remodeling Type on Subsequent Coronary Artery Behavior After Directional Atherectomy Yoshihiro Takeda, MD, Etsuo Tsuchikane, MD, Tomoko Kobayashi, MD, Kenji Yachiku, MD, Kenya Nasu, MD, Nobuhisa Awata, MD, and Tohru Kobayashi, To evaluate the influence of preintervention remodeling on subsequent vessel behavior after directional coronary atherectomy (DCA) under intravascular ultrasound (IVUS) guidance, serial (before and after DCA and at 6-month follow-up) IVUS data were analyzed for 246 lesions that were classified into 2 categories: positive remodeling (PR) in 77 lesions versus intermediate or negative remodeling in 169 lesions. Although the 2 groups had similar baseline characteristics, IVUS data showed that the PR group had a greater acute lumen area (LA) gain without an increased late LA loss, resulting in a greater net (acute From the Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan. Dr. Takeda’s address is: Department of Cardiology, Osaka Medical Center for Cancer and Cardiovascular Diseases, 1-3-3 Nakamichi, Higashinariku, Osaka City, Osaka 5378511, Japan. E-mail: [email protected]. Manuscript received July 25, 2003; revised manuscript received and accepted October 7, 2003. ©2004 by Excerpta Medica, Inc. All rights reserved. The American Journal of Cardiology Vol. 93 February 1, 2004
MD
plus late) LA gain and follow-up LA. This suggests that IVUS-guided DCA may neutralize the negative impact of preintervention PR on late vessel patency. 䊚2004 by Excerpta Medica, Inc. (Am J Cardiol 2004;93:339 –343)
ecent intravascular (IVUS) studies have suggested that preintervention positive remodeling R (PR) associated with a large plaque burden represents 1– 6
a biologically active disease state that may not be particularly well suited for coronary interventions, including stenting. After IVUS-guided directional coronary atherectomy (DCA), we examined serial (before and after DCA and at 6-month follow-up) IVUS data to determine the impact of differences in preintervention remodeling on subsequent vessel change. •••
Criteria for lesion inclusion comprised de novo native coronary artery disease treated with IVUSguided DCA with complete serial (before and after 0002-9149/04/$–see front matter doi:10.1016/j.amjcard.2003.10.016
339