College of Nursing ● University of Kentucky ● Lexington, KY Predisposing Factors for Persistent Symptoms of Depression and Anxiety among Patients with Acute Coronary Syndrome Abdullah S. Alhurani, PhDc, MSN, RN, Gabrielle McKee, PhD,Sharon O’Donnell, PhD, RN, Frances O’Brien, PhD, RN, Mary Mooney, PhD, RN, Martha J. Biddle, PhD, RN , Basel Abdulqader, MSN, RN, CRRN, Terry A. Lennie, PhD, RN FAAN, Debra K. Moser, DNSc, RN, FAAN College of Nursing ● University of Kentucky ● Lexington, KY Background Measures Results Depression and anxiety are highly prevalent in patients with acute coronary syndrome (ACS) contributing to poor health outcomes such as mortality and re-hospitalization. Depression is a common disorder among patients with coronary artery disease and associated with poor outcomes. Around 20% of patients with ACS meet the APA criteria for major depressive symptoms. Anxiety is also common and associated with poor health outcomes. Several studies have also demonstrated a relationship between depression and anxiety and cardiac events in patients with ACS. However, substantial morbidities arise from those patients who persistently suffer from these disorders. Persistent depression and anxiety are a better predictor of ACS event than baseline anxiety or depressive symptoms Patients who been anxious or depressed at baseline and three months follow-up were considered to have persistent anxiety or depressive symptoms. From a list of 21 predefined ACS symptoms, patients were asked to correctly identify those symptoms that could be representative of a heart attack. The total combined knowledge score was 26.For analysis purposes, the score was converted to percentage correct. The attitudes scale had five items which recorded patients’ attitudes and beliefs about ability to recognize symptoms and seek appropriate help in themselves or someone else with ACS symptoms. Scores could range from 5 to 20. Younger age (β 0.98; 95% CI: 0.96 – 1.00; p = 0.040), female gender (β 1.99; 95% CI: 1.30 – 3.05; p = 0.002), history of CABG (β 2.10; 95% CI: 1.18 – 3.71; p = 0.011), history of non ST elevation myocardial infarction compared to other ACS (β 1.78; 95% CI: 1.04 – 3.06; p = 0.037), and baseline anxiety (β 1.40; 95% CI: 1.25 – 1.57; p <0.001) were significant predictors of persistent depression. Furthermore, younger age (β 0.98; 95% CI: 0.96 – 1.00; p = 0.030), female gender (β 1.98; 95% CI: 1.22 – 3.20; p = 0.005), and baseline depression (β 1.24; 95% CI: 1.14 – 1.36; p <0.001) were significant predictors of persistent anxiety. Logistic regression of factors associated with persistent anxiety in ACS patients Analysis Factor (Exp) B Confidence Intervals P value Age 0.976 0.956 -0.998 0.030* Female gender 1.976 1.222- 3.196 0.005* BMI 1.014 0.971 – 1.059 0.590 More than twelve grade education compared to twelve grade or less 0.977 0.536 – 1.059 0.940 Married/ Living with someone compared to Single / separated/ widowed/ divorced 0.988 0.608 – 1.605 0.961 Smoker compared to non-smoker 1.141 0.704 – 1.850 0.592 Diabetic compared to non-diabetic 1.387 0.782 – 2.459 0.263 CABG history 0.503 0.228 – 1.108 0.088 Stroke History 1.351 0.588 – 3.275 0.505 NSTEMI compared to STEMI 0.958 0.527 – 1.744 0.889 Unstable angina compared to STMI 1.234 0.700 – 2.175 0.467 Better knowledge compared to worse knowledge 0.825 0.383 – 1.773 0.622 Attitude 0.994 0.916 – 1.080 0.895 Depressive symptoms baseline 2.184 1.114 – 4.281 <.0001* Descriptive statistics, including mean, standard deviation and frequency distribution, were used to describe sample characteristics. Logistic regression was used to determine predictors of persistent depression and anxiety symptoms. We controlled for baseline anxiety when investigating persistent depression and for baseline depression when investigating persistent anxiety Objective To determine the predictors of persistent symptoms of depression and anxiety among patients with ACS. Method A total of 1199 patients participated from five hospitals in Dublin, Ireland. Patients were recruited from coronary care units and cardiology floors. The inclusion criteria were the following: confirmed diagnosis of ACS patient stable and nearing discharge able to read, understand, and communicate in English. Patients were excluded if they lived in an institutional setting, had very serious complicating comorbidities, or had learning or cognitive disabilities precluding provision of informed consent. Patient were assessed for anxiety and depressive symptoms at baseline and 3-months. Predictive actors were determined by patient interview and by reviewing electronic and non-electronic medical records. Age, gender, body mass index, education level, marital status, smoking history, and diabetes history, history of coronary bypass graft (CABG), stroke, ACS, baseline knowledge and attitudes related to ACS Characteristic N (%) or Mean ± SD Age, years 63 ± 11.9 Anxiety (baseline) 10.29 ± 3.69 Anxiety (3 months) 7.97 ± 4.40 Depressive Symptoms (baseline) 18.70 ± 4.46 Depressive Symptoms (3 months) 16.13 ± 6.29 Body mass index (BMI) 27.47 ± 4.84 ACS Attitudes 14.13 ± 2.89 Gender Male Female 873 (72.8) 326 (27.2) Marital status Single / separated/ widowed/ divorced Married/ Living with someone 409 (34.1) 790 (65.9) Education level Twelve grade or less More than twelve grade 970 (80.9) 229 (19.1) Logistic regression of factors associated with persistent depression in ACS patients Factor (Exp) B Confidence Intervals P value Age 0.980 0.962 - 0.999 0.040* Female gender 1.989 1.298- 3.047 0.002* BMI 1.008 0.968 – 1.050 0.695 More than twelve grade education compared to twelve grade or less 1.230 0.726 – 2.085 0.441 Married/ Living with someone compared to Single / separated/ widowed/ divorced 0.696 0.456 – 1.061 0.092 Smoker compared to non-smoker 1.332 0.872 – 2.036 0.185 Diabetic compared to non-diabetic 1.278 0.756 – 2.160 0.359 CABG history 2.095 1.182 – 3.711 0.011* Stroke History 1.893 0.926 – 3.870 0.080 NSTEMI compared to STEMI 1.781 1.036 – 3.063 0.037* Unstable angina compared to STMI 1.361 0.793 – 2.337 0.264 Better knowledge compared to worse knowledge 1.228 0.619 – 2.435 0.556 Attitude 0.932 0.866 – 1.002 0.057 Anxiety baseline 1.396 1.246 – 1.565 <.0001* Characteristic N (%) or Mean ± SD Current smoker 593 (49.5) Diabetes Mellitus 195 (16.3) CABG history 162 (13.5) Stroke history 72 (6.0) ACS history STEMI NSTEMI Unstable angina 337 (28.1) 408 (34.0) 454 (37.9) ACS symptoms knowledge Worse Knowledge Better Knowledge 604 (50.4) 595(49.6) Measures The Multiple Adjective Affect Checklist (MAACL) was used to measure symptoms of depression and anxiety in this study. Good internal consistency, stability, construct and concurrent validity of the MAACL have been supported. No standard published cut point for the MAACL across the literature, patients were divided based on the 75th percentile into anxious/ not anxious and depressed/ not depressed . Discussion Healthcare providers should have a high index of suspicion for persistent depression and anxiety in patients with these characteristics and consider assessment of anxiety and depression over time.