**8. Gender differences**

The increased operative mortality and morbidity of women compared with men undergoing CABG surgery results from differences in methodology, low number of women in studies reporting negative findings, many studies, both positive and negative, did not take into account preoperative differences in health status between the sexes. Women more frequently have factors associated with increased short- and long-term mortality, such as less common use of internal mammary artery grafts. According to the reported analyses, they are older, less educated, have more severe angina and congestive heart failure, lower functional status, and higher level of depressive symptoms. At time of referral, women are at more advanced disease stage than men; however, despite being more symptomatic, women have less extensive coronary artery disease than men as determined by coronary angiography results [48]. This large number of differences makes the comparison difficult, and studies are not corrected for so many potential imbalances that may influence sex differences in outcome. Additional large prospective studies with substantial numbers of women are needed to evaluate gender-related differences in autonomic responses to myocardial infarction, complications related to cardio‐ pulmonary bypass, susceptibility to abnormalities in coagulation, and other biological factors that might account for discrepant outcomes in men versus women undergoing CABG. Furthermore, specific pharmacologic and therapeutic considerations, such as the role of estrogen replacement therapy, need to be clarified [49]. Compared to conducted studies in this topic the POST CABG Biobehavioral Study enrolled the highest number of women (n = 269) and physical, social, and emotional functioning were investigated after CABG surgery. Both male and female patients improved in physical, social, and emotional functioning after CABG, and recovery over time was similar in men and women. However, women's health-related quality-of-life scale scores remained less favourable than men's women did show less benefit with regard to the symptoms of shortness of breath and tiredness through 1 year after surgery [50]. In another prospective cohort study on quality of life women did not reach the same degree of improvement after 1 year as men, even after adjusting for pre-existing risk factors. Women were at greater risk for subjective cognitive difficulties, increased anxiety and decreased ability to perform tasks for daily living, diminished work-related activities, and reduced exercise capacity [51].

asking about marital status 35% admitted being single. We showed in our study that social isolation was associated with higher mortality after cardiac surgery [27]. Without social network and family support patients face longer hospital stay after CABG. Loneliness increases mortality: in a prospective study 1290 CABG patients were investigated. After controlling for various preoperative factors known to be independently associated with mortality loneliness was found to be associated with mortality, both at 30 days (relative risk 2.61) and at 5 years (relative risk 1.78) after the operation [52]. Kopp et al. found that marital status and spouse support was closely associated with men's mortality. Premature death was significantly lower among married men or men in relationship compared to single men and those who were satisfied with spouse support compared to those who were not [56]. Orth-Gomer et al. reported that following myocardial infarction, women with concomitant marital stress had 2.9-fold increased risk of recurrent cardiac events during a five-year follow-up compared to those with less marital stress after adjustment for age, estrogen status, education level, smoking, diagnosis at index event, diabetes mellitus, systolic blood pressure, smoking, triglyceride level, highdensity lipoprotein cholesterol level, and left ventricular dysfunction [57]. In accordance with this finding, higher prevalence of subclinical atherosclerosis, and accelerated progression over time, among healthy women reporting marital dissatisfaction was reported, assuming that

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

http://dx.doi.org/10.5772/54622

477

Type D personality unifies psychosocial factors related to high cardiovascular risk in one model. Particularly negative affectivity (NA) and social inhibition (SI) are relevant in this context. NA refers to the stable tendency to experience negative emotions across time/ situations. Persons with high-NA experience more feelings of dysphoria, anxiety, and irritability; have a negative view of self; and are looking for signs of impending trouble. NA overlaps with neuroticism and trait anxiety; includes subjective feelings of tension, worry, anxiety, anger, and sadness. SI patients tend to inhibit the expression of emotions/behaviours in social interactions to avoid disapproval by others. They feel inhibited, tense, and insecure when with others. Individuals who are high in both NA and SI have a distressed or Type D personality, given their vulnerability to chronic distress [59]. Type D patients are at increased risk for a wide range of adverse health outcomes, mortality and morbidity, in various cardio‐ vascular populations, including those with ischemic heart disease [60], coronary intervention [61], cardiac arrhythmias [62], peripheral arterial disease [63]. Global left ventricular dysfunc‐ tion and type D personality were independent predictors of long-term cardiac events in patients with a reduced ejection fraction after myocardial infarction [64]. Type D personality independently predicted mortality and early allograft rejection after heart transplantation [65]. In our 5-year follow-up, there was no link between the occurrence of major cardiac and cerebral event and NA and SI after CABG [44]. Additionally, severity of illness intrusiveness, sleeping problems and SI increased in the MACCE positive patients during the three-year period Unfavourable effect of Type D is linked to physiological hyperreactivity, immune activation,

marital stress is atherogenic [58].

**10. Negative affectivity and social inhibition**

and inadequate response to cardiac treatment [59].

### **9. Social support**

Socially isolated persons are single and/or have small social network. Social isolation is associated with poor outcome in established CAD, while high levels of social support is known to promote psychologic and physical well being [52]. Social support can be divided into two broad categories: social networks, which describe the size, structure, and frequency of contact with the network of people surrounding an individual; and functional support, which may be further divided into received social support, which highlights the type and amount of resources provided by the social network, and perceived social support, which focuses on the subjective satisfaction with available support or the perception that support would be available if needed [2]. The underlying mechanisms remain to be identified. Several factors may confound the effect of isolation such as disease severity, or its associations with demographic measures, because socially isolated patients are generally older and of lower socioeconomic status, which are known to reduce survival. Another possible mechanism is the influence of disease progression via its effect on psychosocial functioning. Psychological distress in CAD patients is more severe in patients with lack of adequate social support. Description of the demographic and psychosocial characteristics of those with few social contacts might aid our understanding of the link between isolation and mortality [52]. Previous studies showed the pivotal role of family ties in preserving cardiovascular health [53, 54]. A strong and consistent inverse gradient was reported between the magnitude of social support and adverse clinical outcomes among both initially healthy subjects and those with known CAD [55]. In our study on cardiac surgery patients (180 patients) 17% of patients admitted living alone, however when asking about marital status 35% admitted being single. We showed in our study that social isolation was associated with higher mortality after cardiac surgery [27]. Without social network and family support patients face longer hospital stay after CABG. Loneliness increases mortality: in a prospective study 1290 CABG patients were investigated. After controlling for various preoperative factors known to be independently associated with mortality loneliness was found to be associated with mortality, both at 30 days (relative risk 2.61) and at 5 years (relative risk 1.78) after the operation [52]. Kopp et al. found that marital status and spouse support was closely associated with men's mortality. Premature death was significantly lower among married men or men in relationship compared to single men and those who were satisfied with spouse support compared to those who were not [56]. Orth-Gomer et al. reported that following myocardial infarction, women with concomitant marital stress had 2.9-fold increased risk of recurrent cardiac events during a five-year follow-up compared to those with less marital stress after adjustment for age, estrogen status, education level, smoking, diagnosis at index event, diabetes mellitus, systolic blood pressure, smoking, triglyceride level, highdensity lipoprotein cholesterol level, and left ventricular dysfunction [57]. In accordance with this finding, higher prevalence of subclinical atherosclerosis, and accelerated progression over time, among healthy women reporting marital dissatisfaction was reported, assuming that marital stress is atherogenic [58].
