Psychosocial Effects of Enhanced External Counterpulsation in the Angina Patient

Psychosocial Effects of Enhanced External Counterpulsation in the Angina Patient L.

M.D., KAMIL JAGHAB, M.D. WILLIAM LAWSON, M.D., JOHN C. K. HUI, PH.D. LINA JANDORF, M.A., ZHEN SHENG ZHENG, M.D. PETER F. COHN, M.D., HARRY SOROFF, M.D.

GREGORY

FRICCHIONE,

Enhanced external counterpulsation (EECP) is a noninvasive pantaloon device designed to increase coronary artery flow in the treatment of angina. This pilot study, conducted in 1992-1993, which used psychosocial testing pre- and posttreatment, yielded data suggesting that EECP is well tolerated psychosocially and produces improvement in the anginal syndrome. More comprehensive research is under way to test these preliminary conclusions. (Psychosomatics 1995; 36:494-497)

T

ransient risk factors for sudden cardiac death include psychiatric states of acute and chronic stress mediated through the central nervous system. I There is also a known effect of mental stress on angina.2.3 When the brain triggers a sympathetic nervous system surge, the cardiac vascular and platelet environment may be primed for an ischemic response, resulting in angina.4-6 Enhanced external counterpulsation (EECP) is a noninvasive pantaloon device designed to increase coronary flow in the treatment of angina. The procedure involves wrapping the calves, thighs, and buttocks with balloon cuffs. Synchronous pulsatory pressure is applied sequentially from calves to thighs during diastole, "milking" venous blood back to the heart to increase diastolic pressure and coronary blood flow and to foster collateralization7•8 as well as cardiac output. Pressure is relieved during systole, reducing afterload and cardiac work, thus decreasing myocardial energy requirementsY Patients undergo EECP I hour per weekday for 35 days over 7 weeks, during which time they are strapped to a couch-like undulating EECP 494

apparatus that emits rhythmic thumping sounds (Figure I). Reported here are pilot study findings on psychosocial adjustment to EECP. Several questions were posed. Would such an active, time-consuming treatment be well tolerated psychologically and socially? We hypothesized that the attentive nature of the treatment would be well tolerated and might promote adaptation to illness. Another question was whether an improved psychosocial adjustment in itself could lead to subjective improvements in pain, exercise, and physical well-being? Keeping in mind that mental stress reduction might be Received March 29, 1993; revised May 20, 1993; accepted September 3. 1993. From the Department of Psychiatry and Behavioral Science. SUNY at Stony Brook; the Department of Medicine, Division of Psychiatry, Brigham and Women's Hospital, Boston, MA; the Department of Medicine. Division of Cardiology. SUNY at Stony Brook; and the Department of Surgery. SUNY at Stony Brook. Address reprint requests to Dr. Fricchione. Department of Medicine, Division of Psychiatry. Brigham and Women's Hospital, 75 Francis Street, Boston. MA 02115. Copyright © 1995 The Academy of Psychosomatic Medicine. PSYCHOSOMATICS

Fricchione et al.

physiologically active in reducing myocardial ischemia,3 we postulated that improvement in psychosocial status would have the potential to be both subjectively and objectively effective in reducing symptomatology and ischemia. METHODS Fifteen anginal patients with a history of catheterization documented coronary artery disease (CAD) were consecutively admitted after infonned consent into the protocol of the EECP project at SUNY at Stony Brook. Each patient underwent a Thallium Stress Test with standard Bruce Protocol before starting EECP treatment. 9 The exercise was tenninated due to physical symptoms. One minute before exercise cessation, approximately 2.0 mCi of thallium-20 I was injected intravenously, and scintiphotography of the heart was carried out. Redistribution images were obtained 3 hours later to distinguish infarct from ischemic deFIGURE t.

The enhanced external counter· pulsation device

VOLUME .16. NUMBER 5. SEPTEMBER - OCTOBER 1'i'l5

fects. After a course of EECP treatment, a repeat Thallium Stress Test was perfonned. All patients were given a psychosocial battery preEECP (I day before treatment onset) and post-EECP (on the last day of treatment). This included the Psychosocial Adjustment to Illness Scale-Revised (PAIS-R) and a questionnaire on pain, exercise, and medication needs. HI The PAIS-R is a 46-item self-report measure that evaluates 7 areas of adjustment to illness. A quality-of-life questionnaire examining changes in living habits and general health was given post-EECP only. Twelve out of the 15 subjects completed the PAIS-R. The other three failed to answer all the questions. Nine out of the 12 subjects included in this study also completed the quality-of-life and pain questionnaire in addition to the PAIS-R. RESULTS At baseline all 12 subjects had thallium reperfusion evidence of ischemia. After EECP, 75% (9/12) of the subjects had resolution of ischemia suggested by improved thallium scintiphotography with nonnal Thallium Stress Tests, except for areas scarred by previous myocardial infarctions. II These same subjects showed improved exercise tolerance. The 12 subjects who completed the PAIS-R in the 2 time periods-pre- and post-EECPregimen-were all men. Mean age was 60.2 years (SO = 11.6). The seven subscales of adjustment on the PAIS-R are shown in Table I. The only statistically significant finding on paired '-tests was for the extended family subscale. Given that the range of values for both pre- and post-EECP was generally below the mid-point (t =50), these patients demonstrated a relatively good overall adjustment to their illness. When those who showed improvement in ischemia postEECP (n = 9) were compared with those who showed no improvement (11=3), there was a significant difference on only I of the 14 PAISR subscales (7 pre and 7 post). that of psychological distress. Those with no ischemia improvement had an average PAIS-R score of 495

EECP in the Angina Patient

44.3, with standard deviation of 7.5, compared with those with ischemia improvement, whose score was 52.9, with a standard deviation of 5.2 (P < 0.05). The subjective pain ratings shown in Table 2 demonstrate a significant decrease in the number of times the subjects experienced chest pain and its severity, as well as their use of nitrates to alleviate pain. In addition, on the post-EECP quality-of-life questionnaire, 100% reported an improvement in their ability to work, in energy levels, and in overall well-being. Two out of nine respondents showed no evidence of isTABLE 1.

Psychosocial Adjustment to Illness Scale-Revised (n (2)

=

Subscale

Mean±SD Pre-EECP Post·EECP

Heahh care orientation Vocational environment Domestic environment Sexual relationships Extended family relationships Social environment Psychological distress

59.1 ± 8.9 43.3 ± 7.3 48.7 ± 10.6 47.5±9.9 54.1 ± 7.2 46.6 ± 11.0 54.4 ± 7.6

53.8 ± 8.3 47.3 ± 5.2 44.3 ± 5.5 49.8± 12.1 58.2 ± 6.5' 46.7 ± 9.6 50.8 ± 6.7

EECP =enhanced external conterpulsation. ·P<0.05.

Note:

TABLE 2.

Subjective pain and disability assessment (n 9)

=

Question

Pre-EECP Post·EECP

chemia improvement, yet they reported improvement in quality of life (Table 3). The PAIS-R results suggest that this group of anginal patients was relatively well adjusted to their CAD (see Table I). In the small group without ischemia improvement, there was a significantly greater reduction in psychological distress. The only significant general finding was in the area of extended family relationships. This measure represents a disruption in extended family relationships associated with the illness condition. In our sample, this finding may reflect the time-intensive nature of EECP treatment, with temporary demands made on family systems. In any event, this result, though significant, is not very robust, and in the postEECP questionnaire, 67% felt family life had improved (see Tables I and 3). DISCUSSION Keeping in mind the limitations of this pilot study, in particular the small, all-male sample, a limited psychosocial test battery, and lack of longitudinal follow up, we tentatively conclude, based on objective improvement in ischemia and exercise tolerance as well as on subjective improvements, that for this group of subjects, EECP was primarily an effective physiological treatment for angina apart from any secondary affects owing to reduced stress and apart from any secondary psychological influences. 12- ls However, these latter influences may also be at work. Indeed, three CAD patients who showed no improvement in their thallium images did

How many times did you experience chest pain during the past 3 months (mean ± SO)?

3.9 ± 2.2

0.6 ± 0.7'

How many times did you have to use nitrates to stop the pain (mean ± SO)?

2.3 ± 2.5

0.1 ± 0.4"

TABLE 3.

How severe were those chest pains (mean ± SO)? (I = no pain. 4 = severe)

2.9 ± 0.8

1.7 ± 1.0'"

Change in sexual activity Change in family life 67% Unchanged 33% Unchanged 67% Improved 33% Improved Change in health condition Olange in overall weU-being 100% Improved 100% Improved

Is there any physical limitation 67% Yes on you doing exercise (percentage)? (I = no; 2 = yes)

67% Yes

EECP =enhanced external counterpulsation. ·P
Change in social life 33% Unchanged 67% Improved

Note:

496

Post·EECP quality of life (n

Note:

EECP

=9)

Ability to work 100% Improved Energy level 100% Improved

=enhanced external counterpulsation. PSYCHOSOMATICS

Fricchione et 01.

demonstrate subjective improvement, including more of a reduction in psychological distress than their counterparts. EECP appears to be well tolerated psychosocially, and in a group of more distressed cardiac patients, it might have more striking psychological effects.

Future research into the psychosocial aspects of EECP should include a large, more demographically diverse group of angina patients, a sham treatment period, a more comprehensive psychological test battery, and longitudinal retesting at intervals post-EECP. Such research is now under way.

References I. Fricchione GL, Vlay SC: Psychiatric aspects of patients with malignant ventricular arrhythmias. Am J Psychiatry 1986; 143:1518-1526 2. Natelson BH: Neurocardiology: an interdisciplinary area for the 80s. Arch Neurol 1985; 42: 178-184 3. Rozanski A. Bairey CN. Krantz OS. et al: Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med 1988; 318:1005-1012 4. Selwyn AP. Ganz P: Myocardial ischemia in coronary disease. N Engl J Med 1988; 318:1058-1060 5. McFadden EP. Clarke JG. Davies GJ, et al: Effect of intracoronary serotonin on coronary vessels in patients with stable angina and patients with variant angina. N Engl J Med 1991; 324:648-654 6. Fitzgerald OJ. Ray L. Catella GA: Platelet activation in unstable coronary disease. N Engl J Med 1986; 315:983989 7. Soroff HS. Hui J. Giron F: Current status of external counterpulsation. Crit Care Clin 1986; 2:277-295 8. Banas JS, Brilla A. Levine HJ: Evaluation of external counterpulsation for the treatment of angina pectoris (abstract). Am J Cardiol 1973; 31: 118

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9. Watson DO. Campbell NP. Read EK. et al: Spatial and temporal quantitation of plane thallium myocardial images. J Nucl Med 1981; 22:577-584 10. DeRogatis LR: The psychosocial adjustment to illness scale. J Psychosom Res 1986; 30:77-91 II. Reisman S. Bennan O. Maddahi J. et al: The severe stress thallium defect: an indication of critical coronary stenosis. Am Heart J 1985; 110:128-134 12. Lawson WE, Hui JCK. Soroff HS, et al: Efficacy of enhanced external counter pulsation in the treatment of angina pectoris. Am J Cardiol 1992; 70:859-862 13. Clapp JC. Banas JS. Stickley LP. et al: Evaluation of sham and true external counterpulsation in patients with angina pectoris. Circulation 1974; 50: 101-108 14. Solignac A, Ferguson RJ. Bourassa MG: External counterpulsation: coronary hemodynamics and use in treatment of patients with stable angina pectoris. Cathet Cardiovasc Oiagn 1977; 3:37-45 15. Zheng ZS, Li TM. Kambic H. et al: Sequential external counterpulsation (SECP) in China. Transactions of the American Society of Anificial Internal Organs 1983: 29:5~3

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