The Impact Of Anxiety And Depression On PCI Patients And The Effectiveness Of Mindfulness-based Intervention

BackgroundCoronary artery disease(CAD)is one of the leading causes of morbidity and mortality.The use of drug-eluting stents has been reported to significantly improve the outcomes of CAD patients.However,restenosis and stent thrombosis still pose clinical problems.Traditional risk factors do not fully explain the progression of CAD,the importance of psychological factors,especially anxiety and depression,are being gradually recognized.Most of studies abroad reported the relationship between anxiety or depression and major adverse cardiovascular events(MACEs)in CAD patients respectively.However,Anxiety and depression often occur simultaneously,few studies investigate the influence of anxiety combined with depression on prognosis of CAD patients.Only a few studies have evaluated the impact of anxiety and depression on MACEs in Chinese patients,mostly with short follow-up period or being single-center study.Mindfulness has been reported to improve people's emotion regulation ability.Mindfulness-based interventions have been reported to influence the secretion of cortisol and melatonin(an antioxidant substance),heart rate variability,and oxidative stress.The impact of mindfulness on the above psychological and neurophysiological factors relating to the occurrence and progression of CAD indicates that mindfulness-based interventions may produce significant effects on CAD patients.However,mindfulness-based interventions have rarely been applied in CAD patients.Mindfulness-based interventions'traditional group classroom format and long exercise time were deemed barriers to access for some CAD patients.The development of pracitical intervention programs are warranted.AimThe aim of the study was to explore the impact of anxiety and/or depression on prognosis among CAD patients with stent implantation and to find an intervention to improve symptoms of anxiety and depression for this kind of patients.The specific objectives include:1)to explore the impact of anxiety and depression on MACEs in Chinese CAD patients after stent implantation;(2)to systematically review and assess the probable effectiveness of MBSR on patients with cardiovascular diseases so as to identify if MBSR can be used on CAD patients;(3)to confirm the effectiveness of a six weeks,one-on-one,face-to-face combind with phone-delivered multiform mindfulness-based stress reduction(mMBSR)on the improvement of anxiety,depression,and stress in Chinese CAD patients with stent implantation.MethodsA mixed study design was used.Firstly,an investigation was used to indentify the prevalence of anxiety and depression in CAD patients with stent implantation during hospitalization.MACEs were assessed during the next 12 months and predictive role of anxiety and depression on MACEs was analyzed.Secondly,systematic review of the studies on MBSR for cardiovascular patients was constructed to prepare for the following intervention study.Finally,a randomized controlled trial was conducted to verify the effectiveness of mMBSR on CAD patients and qualitative interview was implemented to understand the underlying mechanism of mindfulness in depth.The concrete methods of this study are as follows:1.The impact of anxiety and depression on cardiovascular events of patients with coronary artery stent implantationPatients who were diagnosed CAD for the first time and met the established criteria were recruited from the First and Second Affiliated Hospital of Soochow University,the Affiliated Hospital of Jiangnan University and the Affiliated Hospital of Nantong University between June 2015 and May 2016.Data regarding baseline demographic and clinical variables,that is,gender,age,martial status,education level,vocation,income,height,weight,current smoking and drinking status,history of hypertension,diabetes,dyslypidemia,family history of early cardiovascular disease,diagnosis,sign of PCI(percutaneous coronary intervention),number of diseased vessel,percentage diameter stenosis,LVEF(left ventricular ejection fraction)and hsCRP(high sensitive C-creative protein).Anxiety and depression were measured using Hospital Anxiety and Depression Scale(HADS).The follow-up was conducted during the next 12 months after PCI.Major cardiovascular events(MACEs)including non fatal new myocardial infarction,in-stent restenosis,repeat revascularization procedure(PCI or CABG(coronay artery bypass grafting)),angina pectoris attacks,heart failure,arrhythmia and death were collected as endpoints and were assessed by telephone interviews and medical records checked.Descriptive analyses were performed for all variables.The difference in MACEs between patients with and without anxiety or depression was tested by the Kaplan-Meier method.A hierarchical Cox proportional hazards regression model was used to adjust for potential confounders and to evaluate the influence of anxiety and depression on time to MACEs.2.Systematic review and meta-analysis of the effects of MBSR on anxiety and depression in cardiovascular patientsMedline,Cochrane Library,Embase,CINAHL,PsycINFO,Science Direct,Web of Science,SinoMed,CNKI and WanFang Data were searched from the earliest date available to June 2016 for randomized controlled trials examining effects of MBSR on cardiovascular patients.Data were analyzed by Review Manager Analysis software version5.3.3.The effectiveness of mMBSR on anxiety and depression in CAD patients with coronary artery stent implantation:A randomized controlled trial(1)Quantitative study70 patients who met the established criteria were recruited within 1-4 days after coronary stent implantation from the First Affiliated Hospital of Soochow University between 22 June 2016 and 4 January 2017 and were randomized equally to experimental or control group.Patients in experimental group received a six weeks,one-on-one,face-to-face combined with phone-delivered MBSR intervention,while patients in control group received routine care.The levels of anxiety,depression,stress and mindfulness were compared between the two groups before and after intervention.The mediating role of mindfulness in the effects of MBSR on improvement of anxiety,depression and stress was analyzed.(2)Qualitative studyAfter intervention,patients who received MBSR were interviewed in depth according to the outline made in advance.Interviews were transcribed to written words and analyzed throughanexplorative-reflectivethematicapproachbasedona hermeneutic-phenomenological epistemology.Themes were extracted and their intrinsic relevance was analyzed.Results1.The impact of anxiety and depression on cardiovascular events of patients with coronary artery stent implantationA total of 328 copies of the initial questionnaire were collected.Among those collected,19 were excluded,and the remaining 309 were considered valid;the effective recovery rate was 94.21%.100 patients(32.36%)had anxiety,80(25.89%)had depression,and 56(18.12%)had anxiety combined with depression.The follow-up period was 21 to 365 days with the average 341.Among the 309patients,MACE occurred in 34(11.00%)patients.The Log Rank test showed that anxiety(?~2=12.043,P=0.001)and depression(?~2=28.753,P<0.001)were associated with a higher rate of MACEs and shorter time to MACEs.In the unadjusted Cox proportional hazards regression analysis,there was significant relationship between anxiety(HR 3.183,95%CI1.607-6.302,P=0.001)and depression(HR 5.348,95%CI 2.677-10.687,P<0.001)and risk of MACEs.After adjustment for sociodemographics and clinical characteristics(ie.,gender,age,BMI,smoking,history of hypertension,diabetes,dyslypidemia,family history of early cardiovascular disease,number of diseased vessel,percentage diameter stenosis,LVEF and hsCRP),Cox analysis showed that anxiety(?~2=31.693,df=14,P=0.004)and depression(?~2=30.382,df=14,P=0.007)were independent predictors of MACEs.Patients with anxiety were 3.741 times(95%CI 1.797-9.178,P=0.004)more likely to have MACEs than those without anxiety.Patients with depression were 3.089 times(95%CI1.324-7.210,P=0.009)more likely to have MACEs than those without depression.We divided patients into four sub-groups:non-anxious non-depressed,anxious but non-depressed,depressed but non-anxious,and anxious and depressed.Survival analysis showed that survival curse did not differ for anxious but non-depressed patients versus non-anxious non-depressed patients(?~2=3.438,P=0.064),or for depressed and anxious patients versus depressed but non-anxious patients(?~2=0.002,P=0.966).There were significant differences for depressed but non-anxious patients versus non-anxious non-depressed patients(?~2=12.385,P<0.001),and for depressed and anxious patients versus non-anxious non-depressed patients(?~2=28.271,P<0.001).Cox regression analysis showed that,compared with non-anxious non-depressed patients,there were significant increases on risk for MACEs in depressed but non-anxious(HR 5.736,95%CI1.875-17.545,P=0.002)and anxious and depressed patients(HR 7.300,95%CI3.092-17.233,P<0.001).Patients with only symptoms of anxiety showed no significant difference in risk for MACEs when compared with non-anxious non-depressed patients(HR 2.790,95%CI 0.912-8.529,P=0.072).2.Systematic review and meta-analysis of the effects of MBSR on anxiety and depression in cardiovascular patientsEight studies with 820 patients were included.Meta-analysis showed that,compared with control,MBSR decreased scores of anxiety[SMD=-0.85,95%CI(-1.69,-0.01),P=0.05],depression[SMD=-0.88,95%CI(-1.67,-0.08),P=0.03],perceives stress MD=-4.66,95%CI(-7.98,-1.35),P=0.006],and systolic[MD=-4.12,95%CI(-5.46,-2.77),P<0.001]and diastolic blood pressure[MD=-1.82,95%CI(-2.76,-0.87),P<0.001],and increased score of psychosocial quality of life[SMD=-2.84,95%CI(0.19,5.49),P=0.04].There was no difference in the significance of the effect of MBSR when a large-sample study was removed from all of the planned analyses except quality of life.3.The effectiveness of mMBSR on anxiety and depression in CAD patients with coronary artery stent implantation(1)Quantitative study5 patients who practiced mindfulness exercise less than 80%of required in the experimental group were treated as withdrawal.4 patients in the control group refused to cooperate and did not complete the questionnaires at final.We finally analyzed the data of patients who completed the intervention and questionnaires,with 30 in experimental and31 in control group.No difference was found in baseline characteristics,levels of anxiety,depression,stress,or mindfulness between experimental and control group.Compared with baseline,levels of anxiety,depression,and stress decreased significantly in the control group,while no difference in proportion of anxious or depressed patients,or mindfulness level was identified.Compared with baseline,levels of anxiety,depression and stress,and proportion of anxious and depressed patients decreased significantly in the experimental group,meanwhile mindfulness level increased significantly.At the end of 6 weeks,significant differences in levels of anxiety,depression,stress and mindfulness,and proportion of anxious and depressed patients appeared between the intervention and control group.Bootstrapping analysis showed that mindfulness played a mediating role in the effects of MBSR on improvement of anxiety,depression and stress.(2)Qualitative studyFive themes were found:(1)finding an inner source of calm,(2)feeling more self-acceptance,(3)re-recognizing disease,(4)focusing on the present,(5)facing the future life with courage.Conclusion1.The prevalence rates of anxiety and depression are high in CAD patients with stent implantation.2.The occurrence of MACEs still poses clinical problems in CAD patients after stent implantation.Depression is an independent predictor of MACEs.The symptom of anxiety combined with depression increases the risk of MACEs significantly.Although anxiety is associated with MACEs,it has no additional value in the case of co-occurring depression.3.Six weeks,one-on-one,face to face combined with phone-delivered multiform MBSR(mMBSR)improves level of mindfulness,symptoms of anxiety,depression and stress among CAD patients with stent implantation.The increase of mindfulness plays a mediating role in the improvement of anxiety,depression and stress.4.Patients who received MBSR experienced significant changes on psychology,cognition and attitude,which were proofs on the increase of mindfulness,and also the intrinsic mechanism relating to improvement of emotion.