C A R D I A C R E H A B I L I TAT I O N
Psychosocial Benefits of Cardiac Rehabilitation Among Women Compared With Men Garrett Hazelton, PhD; Jennifer W. Williams, PhD; Jessica Wakefield, MA; Adam Perlman, MD, MPH; William E. Kraus, MD; Ruth Q. Wolever, PhD
■ PURPOSE: Cardiac rehabilitation (CR) has been shown to reduce cardiac risk and improve the psychosocial functioning of participants. This study examines gender differences on several psychosocial indicators across the course of CR. ■ METHODS: Patients (N = 380; 67.9% men and 32.1% women) referred from local inpatient and outpatient settings at a southeastern US academic medical facility were assessed on reported levels of depression, anxiety, panic, anger, and relationship satisfaction, using the Burns Brief Mood Survey, at the start and conclusion of a CR program. Medical variables were also assessed but are not the focus of this report. Statistical analyses included 1-way, Kruskal-Wallis, and repeated-measures analysis of variance procedures, as well as χ2 analyses. ■ RESULTS: Women reported more psychosocial symptoms at pre-CR than men, and overall, both groups improved across CR. Women with significant depression, anxiety, and panic experienced clinically significant benefit across CR. Although the percentage of men reporting clinically significant levels of anger decreased significantly across CR, clinically significant levels of anger did not significantly change among women. In addition, women did not report benefits in relationship dissatisfaction. ■ CONCLUSION: This study provides further evidence that CR offers psychosocial benefit for women, as has been reported in several small clinical samples. Some notable gender differences on anger and relationship satisfaction were observed. Clinical attention may be warranted to facilitate improvement for symptoms of anger and relationship concerns among selected women who participate in CR.
K E Y
W O R D S
cardiac rehabilitation psychological benefits women
Department of Psychiatric Medicine, East Carolina University, Greenville, North Carolina (Dr Hazelton); Duke Integrative Medicine, Duke University Health System, Durham, North Carolina (Drs Hazelton, Perlman, and Wolever and Ms Wakefield); Carolina Psychological Services, Rocky Mount, North Carolina (Dr Williams); Divisions of General Internal Medicine (Dr Perlman) and Cardiology (Dr Kraus), Department of Medicine, and Department of Psychiatry and Behavioral Sciences (Dr Wolever), Duke University School of Medicine, Durham, North Carolina. The authors declare no conflicts of interest. Correspondence: Ruth Q. Wolever, PhD, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine 102904, Durham, NC 27710 ([email protected]). DOI: 10.1097/HCR.0000000000000034
Psychosocial distress contributes to and exacerbates cardiovascular disease.1 Fortunately, cardiac rehabilitation (CR) effectively improves both medical and psychosocial endpoints, reducing cardiac risk, improving functional capacity, and improving the quality of life of men and women.2-13 www.jcrpjournal.com
Compared with men, however, women with cardiac disease often experience greater medical and psychosocial burden, including higher rates of morbidity, disability, and early death after coronary events.14 These disparities may be related to some combination of factors. First, women report higher Psychosocial Benefits of CR / 21
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-12-00102R4.indd 21
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rates of preexisting psychosocial distress.15 Second, women show notable differences in the pathophysiology of heart disease.16 Third, there is evidence of gender bias, with society assuming that heart disease is a disease of men.17 Finally, compared with men, cardiac disease occurs among women at relatively older ages, when women have lower overall exercise capacity and health status, have lower social support, and are more likely to be widowed.18,19 Gender differences on the psychosocial outcomes of CR have been most commonly reported for depression, anxiety, and the behavioral variables included in cardiac risk.11,13,20,21 Less has been reported on the differential impact across gender of CR on variables such as anger, panic, or relationship satisfaction. Moreover, there have only been limited reports that discuss clinically relevant changes in psychosocial functioning. The purpose of the current study was to further our understanding of the unique psychosocial experience of women completing CR for the first time by examining the statistical and clinical relevance of potential changes in a broad set of psychosocial variables. The aims were to (1) compare medical, demographic, and psychosocial characteristics of men and women preCR; (2) assess for change in psychosocial status and cardiac risk from pre-CR to post-CR; and (3) describe clinically meaningful change in psychosocial status among men and women.
METHODS This retrospective observational study evaluated a convenience sample of 380 CR participants who had completed psychosocial questionnaires pre-CR and immediately post-CR. The patients were referred from local inpatient and outpatient settings to a CR program at a southeastern US academic medical facility. Inclusion criteria required that participants were adults at initial enrollment into CR, able and willing to give informed consent, and provide biomarkers as well as completed questionnaires at both time points. Given our focus on psychosocial outcomes, participants were excluded if their psychosocial data were completely missing for 1 of the 2 time points. Participants were not excluded for missing medical data.
Procedures Patients were assigned by clinic staff to a supervising exercise physiologist or nurse who was responsible for conducting entrance assessments. During this first meeting, informed consent for descriptive research
was obtained, demographic and medical information was collected, and surveys were completed. The clinician was also responsible for monitoring patient progress throughout the program and completing exit assessments. The psychosocial care of patients in this CR program is similar to the standard of care as set forth by the position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation22 and provided by most US CR programs. Patients are provided with three to six 60-minute psychoeducational classes each month that cover topics including the following: psychosocial risk factors (depression, anxiety, anger hostility, and social isolation), their potential influence on coronary disease and treatment adherence, interventions for distress, skills for building social support, effective behavioral change strategies, communication strategies to support treatment adherence, and behavioral change. In addition, a licensed psychotherapist provides 10 to 20 minutes of individual attention for all participants (unless participants refuse or are never available) while they are on the exercise floor, which is intended to establish rapport and provide general psychoeducation. The content of conversations vary, but typically the initial interaction includes discussion of psychosocial risk factors for heart disease (ie, stress management, social support, depression, anxiety), asking them about these factors in their lives, educating them about how these factors can affect the heart, and then suggesting resources (ie, classes, individual therapy, and learning skills such as relaxation techniques) intended to help reduce or modify potential risk factors or situations that contribute to the person's health and quality of life. Second and sometimes third conversations (also 10-20 minutes) occur with approximately 35% to 40% of participants. More visits may occur depending on patient need (ie, experiencing high levels of distress or are requesting support) and patient openness to talk with the provider.
Measures An adaptation of the Brief Mood Survey22 consists of a 25-item self-report inventory that includes multiple 5-item rating scales to assess symptoms of depression, anxiety, panic, anger, and relationship satisfaction over the past week. The 2 depression symptom questions covering suicidal ideation were removed before administration. For depression, anxiety, panic, and anger, individual response options range from 0 (not at all) to 4 (extremely), such that the overall scores on these tests range from 0 (no symptoms) to 20 (the most severe), with higher scores indicating greater symptoms. Scores of 3 and more on subscales of depression, anger, anxiety, and panic symptoms are indicative of clinical levels
22 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34;21-28
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for each respective scale.23-25 The inventory includes a 5-item Likert scale assessing relationship satisfaction, with responses ranging from 0 (very dissatisfied) to 6 (very satisfied). Scores of 25 or less are indicative of relationship dissatisfaction. The Brief Mood Survey has been shown to be valid and reliable, and the measures have been shown to compare favorably with the more well-established and longer tests of psychological status (eg, the Symptom Checklist-90-Revised).23-25 The Framingham Risk score26 is an individualized cardiac risk score that incorporates a number of demographic and behavioral cardiovascular risk factors, including age, gender, smoking status, weight, blood pressure, and cholesterol. Framingham Risk score was included in the current study for 2 reasons: to assess change in cardiac status after the course of CR, and because of the inclusion of psychosocial/ behavioral factors (eg, smoking status) in the cardiac risk score calculation.
Analyses Descriptive statistics provided medical and sociodemographic status of men, women, and the total sample. For normally distributed continuous or ordinal data, gender differences were assessed using 1-way analysis of variance (ANOVA) for pre-CR measures, and 2 (men/women) × 2 (pre/post) repeated-measures ANOVA procedures to assess for gender differences across time. Specifically, gender served as the betweengroups factor, and time served as the within-groups factor in this 2 × 2 design. For variables that could not be adequately transformed to normal distributions by using natural log or square root transformations, Kruskal-Wallis 1-way ANOVA procedures were used to assess pre-CR differences. To test for group × time interactions for such variables, we again used the Kruskal-Wallis 1-way ANOVA procedure to assess gender differences at pre-CR, at the end of CR, and on the delta scores (post-CR minus pre-CR) between genders. We used χ2 test to assess clinically significant change in psychosocial variables and cardiac risk. Percentages of men and women with elevated scores pre-CR were compared with percentages of men and women with elevated scores post-CR.
RESULTS The sample (N = 380) was composed of 32.1% (n = 122) women and 67.9% (n = 258) men. Women were significantly older than men, t(374) = 2.06, P = .04; and there was a higher proportion of African American participants among women. As would be expected, the genders differed with respect to some clinical characteristics and performance on the 6-Minute Walk www.jcrpjournal.com
Test. They were statistically equivalent on other clinical measures, percentage using common cardiovascular drug classes, and importantly, age, authorized and completed CR sessions, and length of time spent in CR. Means and standard deviations for pre-CR sociodemographic and clinical characteristics of the sample are reported in Table 1. Pre-CR, women presented with more favorable Framingham Risk scores than men (P = .002). Both genders, however, experienced improvements in Framingham Risk scores across CR (P < .001). The means and standard deviations of these results are reported in Table 2. In terms of pre-CR psychosocial profiles, the overall sample was in the reference range for symptoms of depression, anxiety, panic, and relationship satisfaction. The overall sample was in the elevated range for symptoms of anger. Evaluating separately by gender, women had anger scores in the elevated range while men did not. Similarly, compared with men, women's pre-CR psychosocial symptom scores were worse for panic (P = .004), depression (P = .023), and relationship satisfaction (P = .008). The means and standard deviations of these results are reported in Table 2. Overall, the sample improved significantly from pre-CR to post-CR on psychosocial measures. More specifically, patients lowered their scores on symptoms of depression, anxiety, anger, and panic, all at P < .001. Improvement across time was not seen in relationship satisfaction (P = .703). The means and standard deviations of these results are also reported in Table 2. No gender × time interactions were observed in the ANOVA tests on psychosocial variables, indicating that the amount of change from pre-CR to post-CR was similar for both genders. Among the 2 psychosocial variables tested with nonparametric statistics, the only variable demonstrating differential change across time was panic. Women demonstrated larger delta scores on panic than did men (P = .024). The means and standard deviations of these results are reported in Table 2. We next explored the degree of clinically significant improvement within each gender. Again, scores of 3 and more on symptoms of depression, anger, anxiety, and panic subscales are indicative of clinical levels for each respective scale; and scores of 25 or less are indicative of relationship dissatisfaction. Regarding symptoms of depression and anxiety, the percentage of participants reporting clinically relevant symptoms significantly decreased from pre-CR to post-CR among both genders. Symptoms of anger and panic presented different pictures. The percentage of men reporting clinically relevant symptoms of anger decreased significantly (P = .03), while the percentage of women did not. Most men did not endorse panic Psychosocial Benefits of CR / 23
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JCRP-D-12-00102R4.indd 23
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T a b l e 1 • Baseline Sociodemographic and Clinic Characteristics of Cardiac Rehabilitation Sample Men (n = 258)
Women (n = 122)
Total (n = 380)
M
SD
M
SD
M
SD
Authorized sessions, n
34.3
6.2
34.1
5.5
34.2
6.0
Completed sessions, n
30.7
8.5
30.2
8.1
30.5
8.4
Program length, d
100.2
55.7
107.2
55.6
102.5
55.7
11.4
a
10.8
a
Measure/Variable
Age, y
64.6
10.5
67.0
65.4
High-density lipoprotein, mg/dL
41.0
13.3
49.38
16.0
43.8
14.7
Low-density lipoprotein, mg/dL
93.3
32.9
100.1
27.3
95.6a
31.2
Cholesterol, mg/dL
161.0
39.6
178.7
35.7
166.9a
39.1
Triglycerides, mg/dL
134.8
79.4
149.1
111.3
139.7
91.5
Heart rate, bpm
71.3
10.8
72.3
9.5
71.7
10.4
Waist circumference, cm
106.3
15.4
99.4
19.8
104.1a
17.3
Systolic blood pressure, mm Hg
123.9
14.0
125.1
16.8
124.3
15.0
Diastolic blood pressure, mm Hg 2
Body mass index, kg/m 6-Minute Walk Test, s
African American
a
8.9 6.8
74.4
8.8
70.7
8.6
73.2
28.8
6.0
29.8
8.1
29.1
479.7
139.8
399.4
119.8
453.2
%
n
%
n
%
10.9
28
20.5
25
a
138.6 n
a
53
a
13.9
Caucasian
85.7
221
76.2
93
82.6
314
Other
3.5
9
3.3
4
3.4
13
ACE inhibitors
54.7
139
44.5
53
51.5
181
β-blockers
83.1
211
84.0
100
83.4
311
Statin
91.3
232
85.7
102
89.5
334
Plavix
45.7
116
54.2
65
48.4
181
Aspirin
93.7
238
90.0
108
92.5
346
Abbreviations: ACE, angiotensin-converting enzyme. a
Significant difference between genders.
symptoms at either time point and change was not significant (P = .13). In women, however, a notable decrease occurred in the percentage that reported clinical levels of panic (P = .005). Neither gender showed a change in relationship satisfaction. These results are reported in Table 3.
DISCUSSION Compared with men, women generally experienced psychosocial and medical benefit after CR at similar rates; however, among participants with clinically relevant symptoms of anger pre-CR, women did not benefit from CR to the same degree as men. Cardiac
rehabilitation did not appear to increase relationship satisfaction, especially notable since women reported relatively low levels of relationship satisfaction. The impact of CR on clinically relevant anger symptoms appears distinct between genders. Although the percentage of men reporting significant levels of anger decreased significantly across CR, the percentage of women reporting significant levels of anger did not significantly change. Anger is important to address since there is evidence of a causal relationship with heart disease,27 and prospective studies from Framingham have shown that anger is specifically associated with heart disease risk in women.28 We found no evidence in the literature suggesting that anger in women is more resistant to improvement
24 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34;21-28
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T a b l e 2 • Description of Psychosocial Variables Pre- and Post-CR by Gender Groups F Scores for Tests of Significance (ANOVA) Pre-CR
Post-CR
Time
Gender
Interaction
2.03 (3.06)
1.47 (2.92)
23.57b
6.53c
0.077
Men (n = 258)
1.85 (3.04)d
1.28 (2.75)
…
…
…
Women (n = 121)
2.42 (3.07)d
1.88 (3.23)
…
…
…
2.84 (3.31)
1.80 (2.82)
53.21b
4.10c
0.054
Men (n = 258)
2.60 (3.15)
1.70 (2.89)
…
…
…
Women (n = 120)
3.30 (3.61)
2.03 (2.67)
…
…
…
3.04 (3.62)
2.30 (3.10)
20.29b
2.80
1.11
Men (n = 258)
2.83 (3.55)
2.26 (3.20)
…
…
…
Women (n = 122)
3.50 (3.75)
2.40 (2.88)
…
…
…
11.55 (7.24)
9.65 (5.95)
53.98b
8.14e
1.32
Men (n = 236)
12.22 (7.60)f
10.06 (6.16)
…
…
…
Women (n = 117)
10.20 (6.27)f
8.81 (5.43)
…
…
…
a
Depression
Overall sample (n = 379)
Anxietya Overall sample (n = 378)
Angera Overall sample (n = 380)
Framinghama Overall sample (n = 353)
χ Scores for Tests of Significance 2
Time
Gender at Time 1
Gender at Time 2
Δ Time by Gender
Panic Overall sample (n = 380) Men (n = 258) Women (n = 122)
0.59 (1.76)
0.23 (0.02)
27.97b
8.34e
0.654
5.08c
0.44 (1.41)f
0.23 (0.92)
…
…
…
…
f
0.90 (2.32)
0.22 (0.69)
…
…
…
…
25.51 (7.01)
25.67 (7.05)
0.145
7.08e
4.95b,c
0.000
26.08 (6.51)f
26.08 (7.00)
…
…
…
…
f
24.77 (7.19)
…
…
…
…
Relationship satisfaction Overall sample (n = 368) Men (n = 253) Women (n = 115)
24.26 (7.88)
Abbreviations: ANOVA, analysis of variance; CR, cardiac rehabilitation. a
Analysis was performed on natural log transformation of data. P ≤ .001.
b
P ≤ .05.
c
Baseline comparisons revealed significant differences by gender at P ≤ .05.
d
P ≤ .01.
e
Baseline comparisons revealed significant differences by gender at P ≤ .01.
f
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Psychosocial Benefits of CR / 25
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T a b l e 3 • Comparison of Clinical Significance of Psychosocial Variables Pre- and Post-CR Within Gender Groupsa Psychosocial Variable
In Clinical Range, %
Tests of Significance
Pre-CR
Post-CR
χ2
P Value
Men (n = 258)
25.2
17.1
8.32
.004
Women (n = 121)
35.5
24.6
5.12
.024
Men (n = 258)
39.9
22.1
30.23
Psychosocial Benefits of Cardiac Rehabilitation Among Women Compared With Men Garrett Hazelton, PhD; Jennifer W. Williams, PhD; Jessica Wakefield, MA; Adam Perlman, MD, MPH; William E. Kraus, MD; Ruth Q. Wolever, PhD
■ PURPOSE: Cardiac rehabilitation (CR) has been shown to reduce cardiac risk and improve the psychosocial functioning of participants. This study examines gender differences on several psychosocial indicators across the course of CR. ■ METHODS: Patients (N = 380; 67.9% men and 32.1% women) referred from local inpatient and outpatient settings at a southeastern US academic medical facility were assessed on reported levels of depression, anxiety, panic, anger, and relationship satisfaction, using the Burns Brief Mood Survey, at the start and conclusion of a CR program. Medical variables were also assessed but are not the focus of this report. Statistical analyses included 1-way, Kruskal-Wallis, and repeated-measures analysis of variance procedures, as well as χ2 analyses. ■ RESULTS: Women reported more psychosocial symptoms at pre-CR than men, and overall, both groups improved across CR. Women with significant depression, anxiety, and panic experienced clinically significant benefit across CR. Although the percentage of men reporting clinically significant levels of anger decreased significantly across CR, clinically significant levels of anger did not significantly change among women. In addition, women did not report benefits in relationship dissatisfaction. ■ CONCLUSION: This study provides further evidence that CR offers psychosocial benefit for women, as has been reported in several small clinical samples. Some notable gender differences on anger and relationship satisfaction were observed. Clinical attention may be warranted to facilitate improvement for symptoms of anger and relationship concerns among selected women who participate in CR.
K E Y
W O R D S
cardiac rehabilitation psychological benefits women
Department of Psychiatric Medicine, East Carolina University, Greenville, North Carolina (Dr Hazelton); Duke Integrative Medicine, Duke University Health System, Durham, North Carolina (Drs Hazelton, Perlman, and Wolever and Ms Wakefield); Carolina Psychological Services, Rocky Mount, North Carolina (Dr Williams); Divisions of General Internal Medicine (Dr Perlman) and Cardiology (Dr Kraus), Department of Medicine, and Department of Psychiatry and Behavioral Sciences (Dr Wolever), Duke University School of Medicine, Durham, North Carolina. The authors declare no conflicts of interest. Correspondence: Ruth Q. Wolever, PhD, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine 102904, Durham, NC 27710 ([email protected]). DOI: 10.1097/HCR.0000000000000034
Psychosocial distress contributes to and exacerbates cardiovascular disease.1 Fortunately, cardiac rehabilitation (CR) effectively improves both medical and psychosocial endpoints, reducing cardiac risk, improving functional capacity, and improving the quality of life of men and women.2-13 www.jcrpjournal.com
Compared with men, however, women with cardiac disease often experience greater medical and psychosocial burden, including higher rates of morbidity, disability, and early death after coronary events.14 These disparities may be related to some combination of factors. First, women report higher Psychosocial Benefits of CR / 21
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-12-00102R4.indd 21
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rates of preexisting psychosocial distress.15 Second, women show notable differences in the pathophysiology of heart disease.16 Third, there is evidence of gender bias, with society assuming that heart disease is a disease of men.17 Finally, compared with men, cardiac disease occurs among women at relatively older ages, when women have lower overall exercise capacity and health status, have lower social support, and are more likely to be widowed.18,19 Gender differences on the psychosocial outcomes of CR have been most commonly reported for depression, anxiety, and the behavioral variables included in cardiac risk.11,13,20,21 Less has been reported on the differential impact across gender of CR on variables such as anger, panic, or relationship satisfaction. Moreover, there have only been limited reports that discuss clinically relevant changes in psychosocial functioning. The purpose of the current study was to further our understanding of the unique psychosocial experience of women completing CR for the first time by examining the statistical and clinical relevance of potential changes in a broad set of psychosocial variables. The aims were to (1) compare medical, demographic, and psychosocial characteristics of men and women preCR; (2) assess for change in psychosocial status and cardiac risk from pre-CR to post-CR; and (3) describe clinically meaningful change in psychosocial status among men and women.
METHODS This retrospective observational study evaluated a convenience sample of 380 CR participants who had completed psychosocial questionnaires pre-CR and immediately post-CR. The patients were referred from local inpatient and outpatient settings to a CR program at a southeastern US academic medical facility. Inclusion criteria required that participants were adults at initial enrollment into CR, able and willing to give informed consent, and provide biomarkers as well as completed questionnaires at both time points. Given our focus on psychosocial outcomes, participants were excluded if their psychosocial data were completely missing for 1 of the 2 time points. Participants were not excluded for missing medical data.
Procedures Patients were assigned by clinic staff to a supervising exercise physiologist or nurse who was responsible for conducting entrance assessments. During this first meeting, informed consent for descriptive research
was obtained, demographic and medical information was collected, and surveys were completed. The clinician was also responsible for monitoring patient progress throughout the program and completing exit assessments. The psychosocial care of patients in this CR program is similar to the standard of care as set forth by the position statement of the American Association of Cardiovascular and Pulmonary Rehabilitation22 and provided by most US CR programs. Patients are provided with three to six 60-minute psychoeducational classes each month that cover topics including the following: psychosocial risk factors (depression, anxiety, anger hostility, and social isolation), their potential influence on coronary disease and treatment adherence, interventions for distress, skills for building social support, effective behavioral change strategies, communication strategies to support treatment adherence, and behavioral change. In addition, a licensed psychotherapist provides 10 to 20 minutes of individual attention for all participants (unless participants refuse or are never available) while they are on the exercise floor, which is intended to establish rapport and provide general psychoeducation. The content of conversations vary, but typically the initial interaction includes discussion of psychosocial risk factors for heart disease (ie, stress management, social support, depression, anxiety), asking them about these factors in their lives, educating them about how these factors can affect the heart, and then suggesting resources (ie, classes, individual therapy, and learning skills such as relaxation techniques) intended to help reduce or modify potential risk factors or situations that contribute to the person's health and quality of life. Second and sometimes third conversations (also 10-20 minutes) occur with approximately 35% to 40% of participants. More visits may occur depending on patient need (ie, experiencing high levels of distress or are requesting support) and patient openness to talk with the provider.
Measures An adaptation of the Brief Mood Survey22 consists of a 25-item self-report inventory that includes multiple 5-item rating scales to assess symptoms of depression, anxiety, panic, anger, and relationship satisfaction over the past week. The 2 depression symptom questions covering suicidal ideation were removed before administration. For depression, anxiety, panic, and anger, individual response options range from 0 (not at all) to 4 (extremely), such that the overall scores on these tests range from 0 (no symptoms) to 20 (the most severe), with higher scores indicating greater symptoms. Scores of 3 and more on subscales of depression, anger, anxiety, and panic symptoms are indicative of clinical levels
22 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34;21-28
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JCRP-D-12-00102R4.indd 22
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for each respective scale.23-25 The inventory includes a 5-item Likert scale assessing relationship satisfaction, with responses ranging from 0 (very dissatisfied) to 6 (very satisfied). Scores of 25 or less are indicative of relationship dissatisfaction. The Brief Mood Survey has been shown to be valid and reliable, and the measures have been shown to compare favorably with the more well-established and longer tests of psychological status (eg, the Symptom Checklist-90-Revised).23-25 The Framingham Risk score26 is an individualized cardiac risk score that incorporates a number of demographic and behavioral cardiovascular risk factors, including age, gender, smoking status, weight, blood pressure, and cholesterol. Framingham Risk score was included in the current study for 2 reasons: to assess change in cardiac status after the course of CR, and because of the inclusion of psychosocial/ behavioral factors (eg, smoking status) in the cardiac risk score calculation.
Analyses Descriptive statistics provided medical and sociodemographic status of men, women, and the total sample. For normally distributed continuous or ordinal data, gender differences were assessed using 1-way analysis of variance (ANOVA) for pre-CR measures, and 2 (men/women) × 2 (pre/post) repeated-measures ANOVA procedures to assess for gender differences across time. Specifically, gender served as the betweengroups factor, and time served as the within-groups factor in this 2 × 2 design. For variables that could not be adequately transformed to normal distributions by using natural log or square root transformations, Kruskal-Wallis 1-way ANOVA procedures were used to assess pre-CR differences. To test for group × time interactions for such variables, we again used the Kruskal-Wallis 1-way ANOVA procedure to assess gender differences at pre-CR, at the end of CR, and on the delta scores (post-CR minus pre-CR) between genders. We used χ2 test to assess clinically significant change in psychosocial variables and cardiac risk. Percentages of men and women with elevated scores pre-CR were compared with percentages of men and women with elevated scores post-CR.
RESULTS The sample (N = 380) was composed of 32.1% (n = 122) women and 67.9% (n = 258) men. Women were significantly older than men, t(374) = 2.06, P = .04; and there was a higher proportion of African American participants among women. As would be expected, the genders differed with respect to some clinical characteristics and performance on the 6-Minute Walk www.jcrpjournal.com
Test. They were statistically equivalent on other clinical measures, percentage using common cardiovascular drug classes, and importantly, age, authorized and completed CR sessions, and length of time spent in CR. Means and standard deviations for pre-CR sociodemographic and clinical characteristics of the sample are reported in Table 1. Pre-CR, women presented with more favorable Framingham Risk scores than men (P = .002). Both genders, however, experienced improvements in Framingham Risk scores across CR (P < .001). The means and standard deviations of these results are reported in Table 2. In terms of pre-CR psychosocial profiles, the overall sample was in the reference range for symptoms of depression, anxiety, panic, and relationship satisfaction. The overall sample was in the elevated range for symptoms of anger. Evaluating separately by gender, women had anger scores in the elevated range while men did not. Similarly, compared with men, women's pre-CR psychosocial symptom scores were worse for panic (P = .004), depression (P = .023), and relationship satisfaction (P = .008). The means and standard deviations of these results are reported in Table 2. Overall, the sample improved significantly from pre-CR to post-CR on psychosocial measures. More specifically, patients lowered their scores on symptoms of depression, anxiety, anger, and panic, all at P < .001. Improvement across time was not seen in relationship satisfaction (P = .703). The means and standard deviations of these results are also reported in Table 2. No gender × time interactions were observed in the ANOVA tests on psychosocial variables, indicating that the amount of change from pre-CR to post-CR was similar for both genders. Among the 2 psychosocial variables tested with nonparametric statistics, the only variable demonstrating differential change across time was panic. Women demonstrated larger delta scores on panic than did men (P = .024). The means and standard deviations of these results are reported in Table 2. We next explored the degree of clinically significant improvement within each gender. Again, scores of 3 and more on symptoms of depression, anger, anxiety, and panic subscales are indicative of clinical levels for each respective scale; and scores of 25 or less are indicative of relationship dissatisfaction. Regarding symptoms of depression and anxiety, the percentage of participants reporting clinically relevant symptoms significantly decreased from pre-CR to post-CR among both genders. Symptoms of anger and panic presented different pictures. The percentage of men reporting clinically relevant symptoms of anger decreased significantly (P = .03), while the percentage of women did not. Most men did not endorse panic Psychosocial Benefits of CR / 23
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
JCRP-D-12-00102R4.indd 23
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T a b l e 1 • Baseline Sociodemographic and Clinic Characteristics of Cardiac Rehabilitation Sample Men (n = 258)
Women (n = 122)
Total (n = 380)
M
SD
M
SD
M
SD
Authorized sessions, n
34.3
6.2
34.1
5.5
34.2
6.0
Completed sessions, n
30.7
8.5
30.2
8.1
30.5
8.4
Program length, d
100.2
55.7
107.2
55.6
102.5
55.7
11.4
a
10.8
a
Measure/Variable
Age, y
64.6
10.5
67.0
65.4
High-density lipoprotein, mg/dL
41.0
13.3
49.38
16.0
43.8
14.7
Low-density lipoprotein, mg/dL
93.3
32.9
100.1
27.3
95.6a
31.2
Cholesterol, mg/dL
161.0
39.6
178.7
35.7
166.9a
39.1
Triglycerides, mg/dL
134.8
79.4
149.1
111.3
139.7
91.5
Heart rate, bpm
71.3
10.8
72.3
9.5
71.7
10.4
Waist circumference, cm
106.3
15.4
99.4
19.8
104.1a
17.3
Systolic blood pressure, mm Hg
123.9
14.0
125.1
16.8
124.3
15.0
Diastolic blood pressure, mm Hg 2
Body mass index, kg/m 6-Minute Walk Test, s
African American
a
8.9 6.8
74.4
8.8
70.7
8.6
73.2
28.8
6.0
29.8
8.1
29.1
479.7
139.8
399.4
119.8
453.2
%
n
%
n
%
10.9
28
20.5
25
a
138.6 n
a
53
a
13.9
Caucasian
85.7
221
76.2
93
82.6
314
Other
3.5
9
3.3
4
3.4
13
ACE inhibitors
54.7
139
44.5
53
51.5
181
β-blockers
83.1
211
84.0
100
83.4
311
Statin
91.3
232
85.7
102
89.5
334
Plavix
45.7
116
54.2
65
48.4
181
Aspirin
93.7
238
90.0
108
92.5
346
Abbreviations: ACE, angiotensin-converting enzyme. a
Significant difference between genders.
symptoms at either time point and change was not significant (P = .13). In women, however, a notable decrease occurred in the percentage that reported clinical levels of panic (P = .005). Neither gender showed a change in relationship satisfaction. These results are reported in Table 3.
DISCUSSION Compared with men, women generally experienced psychosocial and medical benefit after CR at similar rates; however, among participants with clinically relevant symptoms of anger pre-CR, women did not benefit from CR to the same degree as men. Cardiac
rehabilitation did not appear to increase relationship satisfaction, especially notable since women reported relatively low levels of relationship satisfaction. The impact of CR on clinically relevant anger symptoms appears distinct between genders. Although the percentage of men reporting significant levels of anger decreased significantly across CR, the percentage of women reporting significant levels of anger did not significantly change. Anger is important to address since there is evidence of a causal relationship with heart disease,27 and prospective studies from Framingham have shown that anger is specifically associated with heart disease risk in women.28 We found no evidence in the literature suggesting that anger in women is more resistant to improvement
24 / Journal of Cardiopulmonary Rehabilitation and Prevention 2014;34;21-28
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JCRP-D-12-00102R4.indd 24
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T a b l e 2 • Description of Psychosocial Variables Pre- and Post-CR by Gender Groups F Scores for Tests of Significance (ANOVA) Pre-CR
Post-CR
Time
Gender
Interaction
2.03 (3.06)
1.47 (2.92)
23.57b
6.53c
0.077
Men (n = 258)
1.85 (3.04)d
1.28 (2.75)
…
…
…
Women (n = 121)
2.42 (3.07)d
1.88 (3.23)
…
…
…
2.84 (3.31)
1.80 (2.82)
53.21b
4.10c
0.054
Men (n = 258)
2.60 (3.15)
1.70 (2.89)
…
…
…
Women (n = 120)
3.30 (3.61)
2.03 (2.67)
…
…
…
3.04 (3.62)
2.30 (3.10)
20.29b
2.80
1.11
Men (n = 258)
2.83 (3.55)
2.26 (3.20)
…
…
…
Women (n = 122)
3.50 (3.75)
2.40 (2.88)
…
…
…
11.55 (7.24)
9.65 (5.95)
53.98b
8.14e
1.32
Men (n = 236)
12.22 (7.60)f
10.06 (6.16)
…
…
…
Women (n = 117)
10.20 (6.27)f
8.81 (5.43)
…
…
…
a
Depression
Overall sample (n = 379)
Anxietya Overall sample (n = 378)
Angera Overall sample (n = 380)
Framinghama Overall sample (n = 353)
χ Scores for Tests of Significance 2
Time
Gender at Time 1
Gender at Time 2
Δ Time by Gender
Panic Overall sample (n = 380) Men (n = 258) Women (n = 122)
0.59 (1.76)
0.23 (0.02)
27.97b
8.34e
0.654
5.08c
0.44 (1.41)f
0.23 (0.92)
…
…
…
…
f
0.90 (2.32)
0.22 (0.69)
…
…
…
…
25.51 (7.01)
25.67 (7.05)
0.145
7.08e
4.95b,c
0.000
26.08 (6.51)f
26.08 (7.00)
…
…
…
…
f
24.77 (7.19)
…
…
…
…
Relationship satisfaction Overall sample (n = 368) Men (n = 253) Women (n = 115)
24.26 (7.88)
Abbreviations: ANOVA, analysis of variance; CR, cardiac rehabilitation. a
Analysis was performed on natural log transformation of data. P ≤ .001.
b
P ≤ .05.
c
Baseline comparisons revealed significant differences by gender at P ≤ .05.
d
P ≤ .01.
e
Baseline comparisons revealed significant differences by gender at P ≤ .01.
f
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Psychosocial Benefits of CR / 25
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JCRP-D-12-00102R4.indd 25
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T a b l e 3 • Comparison of Clinical Significance of Psychosocial Variables Pre- and Post-CR Within Gender Groupsa Psychosocial Variable
In Clinical Range, %
Tests of Significance
Pre-CR
Post-CR
χ2
P Value
Men (n = 258)
25.2
17.1
8.32
.004
Women (n = 121)
35.5
24.6
5.12
.024
Men (n = 258)
39.9
22.1
30.23
