Patients with chronic angina pectoris who experience incomplete revascularization after percutaneous coronary intervention (PCI) may fare better if they’re optimistic about their own recovery, according to a study published in the American Journal of Cardiology Feb. 7.
Analyses of individuals with chronic angina suggest strong links between depression, severity of patients’ self-reported symptoms and clinical outcomes, Alexander C. Fanaroff, MD, MHS, and colleagues at Duke University Medical Center said. But depression and related mood disorders are just a piece of the psychosocial puzzle.
“The psychosocial contribution to outcomes in patients with acute coronary syndromes (ACS) and stable angina are well-recognized, but recommendations for screening and treatment are largely focused on anxiety and depression,” the authors wrote. “Although expectations for recovery are correlated with, and may be causally related to, depressive symptoms, they are conceptually distinct. Expectations for recovery are part of the way in which patients cognitively process the experience of illness.”
Fanaroff et al. performed a secondary analysis of the RIVER-PCI cohort, a randomized trial of patients with chronic angina pectoris who had incomplete revascularization after PCI. Subjects were asked how much they agreed with the phrase “I am optimistic about my future and returning to a normal lifestyle” at the study’s baseline and one, six and 12 months into follow-up.
The authors evaluated the association between baseline optimism and time to ischemia-driven hospitalization or revascularization in 2,389 patients. Of that pool, 33.2 percent reported being very optimistic at baseline, 42.4 percent reported being optimistic, 19.1 percent were neutral or undecided and 5.2 percent said they were not optimistic.
Compared with optimistic patients, those who weren’t optimistic had a higher prevalence of most comorbidities, including prior myocardial infarction, chronic kidney disease and peripheral artery disease. Index PCIs for non-optimistic patients were less likely to be for an ACS indication, and those patients also had on average more daily or weekly angina, a higher residual SYNTAX following PCI, lower quality of life and lower functional capacity than optimistic patients.
The authors said optimism declined slightly during follow-up, with the proportion of patients reporting high optimism dropping from 33 percent at baseline to 30 percent at one month, 28 percent at six months and 25 percent at 12 months. Among those who reported high optimism at baseline, just 46 percent reported the same thing at one year while 37 percent of the patients were optimistic, 12 percent were neutral and 5 percent weren’t optimistic.
The rate of ischemia-driven revascularization or hospitalization was higher in neutral and not optimistic patients compared to very optimistic patients, Fanaroff and co-authors said, which was something that persisted even after adjusting for comorbidities and baseline angina frequency. Revascularization or hospitalization was 1.42 times more likely in neutral versus very optimistic patients and 1.38 times more likely in not optimistic versus very optimistic patients.
“The mechanism by which optimism affects mortality in patients with coronary artery disease is uncertain; however, a separate mechanism is likely to underlie the link we observed between patient-reported symptoms of angina and subsequent revascularization and hospitalization,” the team wrote. “Angina is an intrinsically variable condition, and is often only weakly correlated with objective myocardial ischemia, and healthcare utilization for angina is driven largely by patient-perceived symptom burden.
“In patients with coronary artery disease, observed negative mood is more predictive of chest pain during exercise testing than ST-segment depression, and greater perceived risk of MI is more strongly associated with self-reported angina during activities of daily living than ischemia on stress imaging.”
The authors said patients’ expectations and beliefs about their illness can be changed through interventions that focus on explaining the pathophysiology of MI, exploring negative beliefs about recovery and developing written action plans for avoiding CV risk factors and recovering normally.
“Until then, healthcare providers caring for patients with chronic angina should routinely ask patients how optimistic they are about returning to normal functioning,” Fanaroff and colleagues said. “They should remind those with low levels of optimism that their prognosis for returning to a normal level of functioning may be quite good.”