**12. Interventions**

non-Type Ds (13 of 34, or 38%), adjusting for other risk factors (odds ratio: 6.75; 95% confidence interval: 1.47 to 30.97) (p =

0.014).

**Table 3.** Some important studies about negative affectivity and socal inhibition in cardiology

Previous research showed that educational level is an important health determinant, with gender-related differences and ethnic and cultural variations. Low educated men and women, in particular with required schooling only, have usually low income and thus lower socioeconomic status may be expected. The lower education level of older persons leads to greater burden for medical services and lower awareness of how to lead a healthy lifestyle, and lower adherence to medication and utilisation of preventive measures. In general, women take part more often in screening programs, are more interested in health prevention and visit their general practitioners more often. Their activity may also relate to a higher rate of diagnosis of depression and anxiety disorders. Besides biological factors including oestradiol, psychosocial factors, culture and education may be responsible for the prevalence of these mental disorders among women [66]. Less education was showed an important risk factor for late-life depres‐ sion [67]. In survey in South America women's higher education was associated with lower risk for diabetes and hypertension and lower BMI in all areas but more strongly in urban areas. There was no association or even an adverse association between education and these risk factors among men in less urban areas [68]. Controversially, men with low level of education were related to higher BMI, prevalence of diabetes and smoking. Less-educated women had higher blood pressure and BMI and low education in both sexes was associated with twofold increased incidence of stroke and CHD [69]. In an Austrian study both men and women with lower educational levels were associated with unhealthy behaviours, overweight and higher cardiovascular risk. There was in inverse relationship in both men and women between overweight and obesity and educational level. The odds of daily smoking, eating a diet rich in meat and doing no regular vigorous exercise decreased with increasing educational level. Among women, the odds of suffering from diabetes or from hypertension decreased gradually with increasing educational level. There was no clear association between educational level and the risk of diabetes or hypertension in men. Depression among women with only required schooling was frequent, but showed no relationship with education in men [66]. Low education and income are important determinants of all-cause mortality and cardiovascular mortality [70] among patients with myocardial infarction. Low income and education are related to a higher risk profile and poorer treatment [71]. In accordance, in our study, a higher level of education was associated with a longer survival time after CABG. Those patients who had an academic degree had a mean survival time of 8.01 years, patients with 9 to 12 years of education had a mean survival time of 7.73 years and the group with 8 years or less of education had a mean survival time of 7.03 years. There were significant differences among patients with 8 years or less of education and patients with 8 to 12 years of education and patients with an

**11. Education**

480 Artery Bypass

The American Heart Association has recommended routine screening by self- reporting meas‐ ures to rapid identification of likely depressed CAD patients. The Patient Health Questionnaire is one such depression assessing measurement, focuses on two requisite symptoms for a depres‐ sion or major depressive episode diagnosis, i.e., (1) little interest or pleasure in doing things, (2) feeling down, depressed, or hopeless. Patients with positive screening results should be evaluat‐ ed by a professional qualified in the diagnosis and management of depression [5].

#### **12.1. Antidepressants**

There are currently several empirically validated treatments for depression. A national survey of cardiovascular physicians reported nearly 50% of respondents treat the symptoms of depression once identified in patients with CAD [73]. The Selective serotonin re-uptake inhibitors (SSRI) are currently considered the safest to use with CAD patients, in contrast to the tricyclics, which may have pro-arrhythmic and cardio-toxic effects. The SSRI have been hypothesized as safe among cardiac patients due to the serotonin transporter affinity and attenuation of platelet functioning. The SADHART trial compared the effects of sertraline and placebo for 24 weeks in major depressive patients with unstable angina or recent MI. The SSRI treatment did not adversely affect cardiac function and was considered to be safe for most patients [74]. However, in the ENRICHD trial, improvements in depression were rather modest. Patients with at least 1 prior episode of depression or more severe depression showed consistent improvement in depression relative to control, suggesting that treatment with SSRIs is a good option for this subset of depressed CAD patients. The ENRICHD trial also found that antidepressant treatment improved prognosis for myocardial infarction patients, they were at decreased risk for death and reinfarction compared with those who did not take antidepres‐ sants [75]. In a systematic review [76] only 2 studies had follow-up periods that were long enough to assess cardiac outcomes [76, 77]. None of them found evidence of an effect of depression treatment. Two studies reported that selective serotonin reuptake inhibitors did not affect cardiac function [74, 79]. Possible side effects of SSRIs for CABG surgery patients include increased bleeding, but have not been consistently supported [80]. One study sug‐ gested an increased long-term mortality and rehospitalization after CABG surgery attributable to SSRIs [81]. Another study indicated greater renal morbidity and ventilation times, but not greater mortality or bleeding risk [82]. In two recent systematic reviews of randomized, controlled trials in CAD patients both established SSRI vs. placebo there was no difference in mortality and differential findings were reported on hospital readmissions. One found reduced odds [83], whereas another review did not when applying stringent criteria for properly randomized studies [84]. There is no trial about the role of anxiolytic drugs before or after CABG with or without concomitant depressive symptoms.

disorders is important in any context, there is not sufficient evidence whether interventions among cardiac patients can promote and maintain health related behaviour change [25]. Exercise is commonly recommended to promote both primary and secondary CAD preven‐ tion, but evidence suggests that exercise may also modify psychosocial risk factors, including depression. Cross sectional studies of both patients and healthy cohorts have consistently demonstrated lower depression rates among those who are most active [55]. A randomized controlled comparison between antidepressant medication versus exercise was performed in depressed patients. After 16 weeks, there was a significant reduction in depression in all groups, confirming the same effect of exercise and sertraline hydrochloride in reducing depressive symptoms. However, a lower rate of relapse was observed in the exercise group

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

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

483

Coronary artery bypass graft surgery (CABG) is a confirmed procedure to relive angina pectoris and reduce the risk from life-threatening ischaemic heart disease, besides reducing the likelihood of future heart attacks and prolonging life-expectancy. Another goal is to improve health-related quality of life and psychological well-being. After successful surgery the majority of patients can have an improved everyday life, with increased performance in physical, social and sexual functioning and decreased levels of depression, anxiety, fatigue and sleep. In some cases quality of life for patients can be disappointing, and attention has increasingly been paid to psychological difficulties following CABG surgery [92]. Psycholog‐ ical problems such as depression and anxiety are widely reported soon after CABG surgery and remain evident for around one-fifth of patients one year after surgery. Poor psychological adjustment following surgery can increase the likelihood of new coronary events, further hospitalisations and even death. According to a recent study 30% of patients have reduced health related quality of life without being clinically anxious or depressed they present with fear of activity, fear of excitement, give up enjoyed hobbies / activities. Evidence suggests that self-perceived health related quality of life, depressive symptoms and anxiety together influence the short and long term recovery following coronary bypass surgery [93]. There is also a higher risk for morbidity and mortality among the lonely and the socially isolated, they are likely to have prolonged postoperative recovery and hospital stay. Lower education and poor social background are associated with higher mortality rates related to CHD and prolonged hospital stay after CABG [93, 94]. Further research on the interaction between these disorders and social factors may improve our understandings and uncover promising ways for intervention. Most studies to date focus on depression, the role of other factors alone or

In conclusion, compared with community samples the prevalence of depression and anxiety disorders are significantly higher and they confer greater morbidity risks, though the behav‐ ioural and biological mechanisms are poorly understood. Researchers and clinicians hope psychosocial intervention might decrease or cease the deleterious impact of depression and

after six months [91].

**13. Conclusion and future directions**

investigated together warrants further research.

anxiety on morbidity and mortality.

### **12.2. Psychosocial Interventions**

Psychosocial interventions (psychotherapy, support, stress reduction) have been used as treatments for depression in CAD patients. The aim of these interventions is to reduce psychological distress, which in theory would ultimately improve clinical outcomes. Patients with depression often do not participate or complete cardiac rehabilitation programs after CABG and thus may form a barrier to improvements in cardiac functioning [85]. From another aspect, isolated patients may be difficult to enroll in interventions because they do feel that they have a problem. Without the experience of need, motivation to change may be low [86]. Numerous behavioural and psychological randomized controlled trial (RCT) interventions have been reported and cognitive behavioural therapy or collaborative care constitutes Class IIa evidence (i.e., it is reasonable to administer treatment, additional studies with focused objectives are needed) [85]. In one of RCT studies on brief, tailored cognitive behavioural therapy targeting preoperative depression and anxiety researchers found that intervention improved depressive and anxiety symptoms, as well as quality of life. Moreover, it reduced in-hospital length of stay [87]. In a Canadian study eight weeks prior to CABG, the treatment group received exercise training twice per week, education and reinforcement, and monthly nurse-initiated telephone calls. After surgery, participation in a cardiac rehabilitation program was offered to all patients. The intervention was not associated with differences in pre-surgery anxiety versus usual care, however length of stay differed significantly between groups. Patients who received the preoperative intervention spent 1 less day in the hospital overall and less time in the intensive care. During the waiting period, patients in the intervention group had a better quality of life than controls. Improved quality of life continued up to 6 months after surgery. Mortality rates did not differ [88]. In a prospective randomized control‐ led trial the effects of a home-based intervention program on anxiety and depression 6 months after CABG were assessed. Anxiety and depression symptoms were measured before surgery, 6 weeks after surgery, and 6 months after surgery. On 6-week and 6-month follow-ups, significant improvements in anxiety and depression symptoms were found in both groups. There was no significant difference between patients receiving interventions and not [89]. Freedland et al. compared cognitive behaviour or supportive stress management vs usual care and found significant three month depression remission rates in the treatment arms. Cognitive behaviour therapy had greater and more durable effects than supportive stress management on depression and several secondary psychological outcomes [90]. The limitation of psycho‐ social RCTs among CABG populations is that those patients experiencing significant postoperative morbidity are likely to be excluded from trial inclusion. Therefore, less is known about long term outcomes for patients who experience stroke, deep sternal wound infection, sternal dehiscence, renal failure requiring dialysis and extended length of time on mechanical ventilation, or intensive care during their hospital stay. These moribund patients are at higher risks for developing or exacerbating psychological distress. Moreover, treatment of affective disorders is important in any context, there is not sufficient evidence whether interventions among cardiac patients can promote and maintain health related behaviour change [25]. Exercise is commonly recommended to promote both primary and secondary CAD preven‐ tion, but evidence suggests that exercise may also modify psychosocial risk factors, including depression. Cross sectional studies of both patients and healthy cohorts have consistently demonstrated lower depression rates among those who are most active [55]. A randomized controlled comparison between antidepressant medication versus exercise was performed in depressed patients. After 16 weeks, there was a significant reduction in depression in all groups, confirming the same effect of exercise and sertraline hydrochloride in reducing depressive symptoms. However, a lower rate of relapse was observed in the exercise group after six months [91].
