1. 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
0.030*
Female gender
1.976
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
0.040*
Female gender
1.989
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.