**1. Introduction**

Coronary heart disease (CHD) is the commonest form of heart disease in the developed world, and one of the leading causes of mortality and morbidity in these countries. Over the past decades numerous studies focused on the link between CHD and different psychosocial factors. The prevalence of depression in patients with diagnosed CHD is quoted between 20 and 45%. Elevated anxiety scores have been reported for 20 to 55% [1]. Emotional factors and the experience of chronic stress contribute to the development of atherosclerosis and cardiac events. Emotional factors include affective disorders such as major depression and anxiety disorders as well as hostility and anger. Chronic stressors include factors such as low social support and low socioeconomic status [2]. Similar prevalence ratios have been found for patients undergoing coronary artery bypass graft surgery (CABG). Symptoms of anxiety and unipolar depression are common psychological disturbances among patients undergoing CABG surgery. Numerous prospective cohort studies focus on the short and long term outcome of CABG. Research revealed that not only clinical factors e.g. cardiac status, comor‐ bities and intraoperative factors have impact on the outcome [3]. Comparison of morbidity and mortality rates associated with psychosocial factors to morbidity and mortality rates related to traditional risk factors (smoking, obesity, and physical inactivity) showed priority of psychosocial background [4].

The purpose of this review is to provide a selected summary of key findings in this literature. We summarize some of the classic studies and historical developments important to the field and focus on prospective data on cardiac surgery patients. We review the literature on the important psychosocial domains (depression, anxiety, self rated health, happiness, illness intrusiveness, quality of life, gender differences, social support, negative affectivity, social inhibition, education) that have received much of the research attention, discuss key patho‐

© 2013 Cserép et al.; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

physiological mechanisms and pathways by which psychosocial factors may influence the outcome after surgery, and discuss some treatment directions likely to be critical to advancing the field.

significantly related to cardiac mortality for both genders (the odds ratio for women was 3.29, for men, the odds ratio was 3.05). Data were controlled for other multivariate predictors of mortality (age, Killip class, the interactions of gender by non-Q wave myocardial infarction, gender by left ventricular ejection fraction, and gender by smok‐ ing) and showed that depression was independent predictor for either gender [8]. Most studies that have examined the relationship between increasing depression severity and cardiac events have shown a dose-response relationship: in a 5-year-follow-up study postmyocardial infarction patients were recruited and assigned to categories based on the severity of depressive symptoms, ranging from no depressive symptoms to moderate to severe depressive symptoms. During follow-up period, a gradient relationship was observed between the magnitude of depressive symptoms and the frequency of deaths, with increased events occurring even in patients with mild depressive symptoms [9]. In the prospective study of Brown et al. elderly adults with significant depressive symp‐ toms at baseline and without a current diagnosis of CHD at baseline were more likely to experience a cardiac event over a 15-year follow-up period. Depressed patients were 1.5 times more likely to suffer a cardiac event (i.e., acute myocardial infarction or cardiac death), even after controlling for demographics and known cardiovascular risk factors. The elevated depressive symptom severity is a predictor of cardiac events among older women and men as well as older white and black adults [10]. Despite methodological differences (sample sizes, sample characteristics, selection of covariates, etc) from study to study, the data from prospective studies with objective outcome measures and validated question‐ naires for depression are remarkably consistent in their results suggesting depression is a

Short and Long Term Effects of Psychosocial Factors on the Outcome of Coronary Artery Bypass Surgery

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risk factor for both the development of and the worsening of CHD [5].

CABG surgery is a common surgical intervention for CHD patients and prevalence of depression before or after CABG surgery is about 20–25% [4]. The presence of elevated levels of depressive symptoms results in a higher risk of mortality and significantly increased overall risk of major cardiac events following cardiac surgery [11]. In the prospective study of Connerney et al. 309 CABG patients were followed for 1 year after surgery. Compared with non depressed patients, depressed patients were more than twice as likely to have a cardiac event within 12 months after surgery but were not at higher risk for mortality within the first year [4]. In a larger sample of 817 CABG patients followed for up to 12 years, Blumenthal et al. assessed the effect of depression on mortality after CABG surgery. Depression was assessed both at baseline and 6 months after surgery. Results indicated that moderate to severe depression on the day before surgery as well as depression that persisted from baseline to 6 months after surgery were associated with 2-fold to 3-fold increased risk of mortality after adjustment for other risk factors [3]. Readmission following cardiac surgery is a significant burden on the healthcare system. In a prospective study, 226 CABG patients completed baseline self-report measures of depression, anxiety and stress and 222 patients completed these measures after surgery on the hospital ward. In multivariable analyses more than twofold increase in readmission risk was associated with preoperative anxiety and postoperative depression, independent of covariates [12]. When our work group investigated the relation‐

**2.2. Depression and CABG**
