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ORIGINAL ARTICLE
Year : 2022  |  Volume : 15  |  Issue : 5  |  Page : 746-751  

Evaluation of quality of life, type D personality and emotional factors in patients undergoing angioplasty- A Prospective study


Department of Psychiatry, Dr D.Y. Patil Medical College, Dr D Y PatilVidyapeeth, Pimpri, Pune, Maharashtra, India

Date of Submission26-Nov-2021
Date of Decision27-Mar-2022
Date of Acceptance20-May-2022
Date of Web Publication11-Jul-2022

Correspondence Address:
Dr. Suprakash Chaudhury
Department of Psychiatry, Dr D.Y. Patil Medical College, Dr D Y PatilVidyapeeth, Pimpri, Maharashtra, Pune
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_918_21

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  Abstract 


Background: Percutaneous coronary intervention (PCI) has been effective in increasing the longevity of patients with cardiovascular disease. Notwithstanding paucity of Indian studies on the psychological effects of PCI, there have been conflicting evidences with regard to improvement of quality of life in patients undergoing angioplasty. Aim: To evaluate change in the quality of life and emotional factors like depression, stress, and anxiety in patients undergoing angioplasty. Methods: This prospective longitudinal study was carried out at a tertiary care hospital and research centre in the western part of Maharashtra in a semi-urban location on 70 consecutive patients undergoing angioplasty from July 2019 to July 2021. Besides sociodemographic data patients were assessed with Type D Scale-14 (DS14), Depression Anxiety Stress Scale, and The MacNew heart disease health-related quality of life Questionnaire. After 15 days of the procedure, patients were re-evaluated with the same scales. Results: Mean age of our study population was 58.67 years of which 77.14% were men. The prevalence of Type D personality was 28.57%. There was a significant reduction in anxiety and stress scores and significant improvement in emotional and physical sub scales of Quality of life post angioplasty. On multiple regression analysis, anxiety and social inhibition emerged as predictors of depression. Conclusion: Angioplasty is associated with significant improvement in anxiety, stress, and emotional and physical subscales of Quality of life. Social inhibition, which is a component of Type D personality, anxiety, and loss of libido are significant predictors of depression in patients undergoing angioplasty.

Keywords: Anxiety, coronary angioplasty, depression, MacNew heart disease health-related quality of life questionnaire, stress, type D scale-14, type-D personality


How to cite this article:
Sowmya A V, Khan A, Vijay P, Chaudhury S, Javadekar A, Chigullapalli S, Saldanha D. Evaluation of quality of life, type D personality and emotional factors in patients undergoing angioplasty- A Prospective study. Med J DY Patil Vidyapeeth 2022;15:746-51

How to cite this URL:
Sowmya A V, Khan A, Vijay P, Chaudhury S, Javadekar A, Chigullapalli S, Saldanha D. Evaluation of quality of life, type D personality and emotional factors in patients undergoing angioplasty- A Prospective study. Med J DY Patil Vidyapeeth [serial online] 2022 [cited 2022 Nov 26];15:746-51. Available from: https://www.mjdrdypv.org/text.asp?2022/15/5/746/350689




  Introduction Top


Coronary heart disease (CHD) is now the leading cause of death worldwide. Its rise has become a true pandemic that respects no borders. During the last forty years, results from observational and intervention studies have clearly shown that CHD is partially preventable.[1] Knowledge of this has been implemented in some populations more than in others, which may explain the heterogeneous changes that have taken place in CHD incidence and mortality among different places around the world.[2] In India at present Cardiovascular diseases (CVDs) are the leading cause of mortality responsible for about 24.8% of all mortality. Ischemic heart disease and stroke are the major causes and account for >80% of CVD deaths. The Global Burden of Disease study reported an age-standardized CVD death rate of 272 per 100 000 population in India which is much higher than the global average of 235 per 100 000 population.[3] Despite the availability of various therapeutic strategies such as medications, angioplasty, and bypass grafting surgery for the treatment of the CHD, angioplasty remains the most common method of treatment. Angioplasty can also improve symptoms of blocked arteries, such as chest pain and shortness of breath.[4]

Health-related quality of life assessment of patients is an indicator for evaluating the effectiveness of medical interventions. The World Health Organization defines the quality of life (QOL) as “individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, ambitions, standards, and interests”.[5] The quality of life reflects secondary psycho-emotional benefits for the patient. The decrease in physical limitations, improvement of perception, and health status are the benefits of a successful coronary angioplasty. It is thus expected that the QOL will be promoted in patients with coronary arteries after angioplasty. Although angioplasty is an effective method in the treatment of heart disease, its effect in QOL may not be favorable in all cases.[6] In fact, coronary artery problems have a progressive course with multiple internal and external factors unless treated effectively that influence patients' QOL. Additionally, personality traits are considered as broad dimensions of individual differences between people and the way they engage with the environment.[6] They underpin the consistency with which people think, act, and feel across different situations and over time. There has been much taxonomy of personality traits. Initially, Type A personality which encompasses individuals who are highly competitive, ambitious, work-driven, and time-conscious, was considered a risk factor for CHD. Subsequently, Type D or the distressed personality type was formulated by Denollet in response to the findings that depression and low perceived social support are related to cardiovascular morbidity and mortality. He proposed a personality type that might predispose people to depression and social isolation by combining two personality traits, namely negative affectivity (the tendency to experience negative emotions) and social inhibition, or the tendency to inhibit self-expression in social interactions. Type D personality has been shown in a series of studies to predict adverse clinical outcomes in patients after acute coronary syndrome and revascularization, and in patients with CHD.[7] It has also been associated with heightened pro-inflammatory cytokine activation in patients with heart failure and with disturbances in cortisol secretion after CHD.[8],[9] There is a paucity of research material available regarding the association between Type D personality and CHD in the Indian population. Negative emotions such as depression, anxiety, and stress on the other hand have always been thought to play a role in the etiology of CHD.[10],[11] Several narrative and quantitative reviews and descriptive epidemiological studies have concluded that depression and anxiety predict CHD morbidity and mortality, even after traditional CHD risk factors, such as serum cholesterol, blood pressure, and smoking, are controlled.[12] In view of the increasing number of angioplasties, paucity of Indian studies on its impact on quality of life, and its impact on negative emotions, the current study was undertaken to evaluate quality of life, Type D personality, and emotional factors in patients undergoing angioplasty.


  Materials and Methods Top


This prospective longitudinal study was carried out at a tertiary care hospital and research centre in Pune. The study was undertaken after approval from the institutional ethical committee (IESC/PGS/2019/56 dt 08/11/2019). Written informed consent was obtained from all patients recruited in the study after explaining the purpose and design of the study. The study was undertaken from July 2019 to July 2021.

Sample size

Sample size is calculated using the following formula



N = required sample size

T = confidence level at 95%

P = estimated prevalence of coronary angioplasty

M = margin of error at 5%





N = 140

Due to the COVID-19 pandemic, only 70 Patients who were posted for angioplasty by the Cardiologist in a cardiac catheter laboratory at a tertiary care hospital were included in the study.

Inclusion criteria

  1. Patients posted for angioplasty.
  2. Patients who are stable and are able to answer questions.


Exclusion criteria

  1. Patients who have a pre-existing psychiatric illness.
  2. Patients who are unable to give consent and participate in the study.


Tools

Socio- demographic and clinical proforma

A specially designed proforma was used to collect demographic clinical details of the patients.

The Mac new heart disease health-related quality of life questionnaire (MacNew)

The MacNew is a clinician-rated scale and contains 27 items. Internal consistency reliability of the Indonesian MacNew was confirmed with Cronbach's α of the global scale and all three subscales exceeding 0.95. Test-retest reliability was acceptable with an intraclass correlation coefficient of 0.66 for the global score. Furthermore, an acceptable concurrent validity was established with a statistically significant correlation between Indonesian MacNew and SF-36 (Pearson correlation ranging from 0.47 to 0.71).[13],[14]

Type D scale-14 (DS14)

The DS14 was designed to assess Negative affect (NA) and social inhibition (SI). The reliability of Type D assessment was good, with Cronbach's α for negative affectivity and social inhibition of 0.86 and 0.79. Factor analyses confirmed the two-factor model of the Type D construct.[15]

Depression anxiety stress scale-21 (DASS-21)

The DASS-21 scale was devised to assess depression, anxiety, and stress. It consists of 21 items. The reliability of DASS-21 was good with Cronbach's alpha values of 0.81, 0.89, and 0.78 for the subscales of depression, anxiety, and stress, respectively. It was also found to have excellent internal consistency, discriminative, concurrent, and convergent validities.[16]

Methodology

The study was conducted at a Cardiology unit of a tertiary care centre. All patients admitted to the hospital for angioplasty and meeting the inclusion and exclusion criteria were included in the study. Patients were interviewed prior to angioplasty and fifteen days after the procedure. During the initial interview, demographic and clinical data were recorded. Prior to the procedure, patients were assessed with DS14, DASS-21, and the MacNew Questionnaire. Details of cardiac evaluation, laboratory investigations, and angioplasty details were recorded from the case notes. After 15 days of the procedure, the patients were re-evaluated using DASS-21 and the MacNew Questionnaire. The scales were scored as per the manual of the scale. The collected data were tabulated and statistically analyzed.

Statistical analysis

SPSS software (IBM, Atlanta, USA) was used to analyze the data. The mean, standard deviation, percentage, and other descriptive statistics were provided and a Chi-square test of significance and Fisher exact test were performed. Wilcoxon Signed Ranks test was used to compare the quality of life, depression, anxiety, and stress pre and post angioplasty. Spearman Correlation was used for correlation.


  Results Top


This study was conducted on 70 patients posted for angioplasty. Socio-demographic and clinical characteristics of study participants are listed in [Table 1]. The prevalence of Type D personality in CHD patients undergoing angioplasty was 28.57%. We observed a significant reduction in prevalence and scores of anxiety and stress post angioplasty but no significant change in depression [Table 2], [Table 3], [Table 4]. We also observed a significant improvement in emotional and physical subscales of quality of life [Table 5]. On multiple regression analysis, anxiety and social inhibition emerged as significant predictors of depression. [Table 6], [Table 7], [Table 8].
Table 1: Represents socio demographic and clinical characters of study population

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Table 2: Prevalence of depression pre and post angioplasty amongst study population (n=70)

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Table 3: Represents anxiety pre and post angioplasty amongst the study population

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Table 4: Prevalence of stress pre and post angioplasty amongst study population (n=70)

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Table 5: Comparison of components of Quality of life pre and post angioplasty

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Table 6: Multiple regression analysis for predictors of postangioplasty depression: Model Summarye

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Table 7: Multiple regression analysis for predictors of postangioplasty depression: ANOVAa

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Table 8: Multiple regression analysis for predictors of postangioplasty depression: Coefficientsa

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  Discussion Top


Mean age of our study participants was 58.67 years [Table 1] which was similar to 61.8 years plus or minus 10.0 years in an earlier study on 300 patients undergoing angioplasty.[17] Our study population comprised 77.14% men and 22.86% women. This indicates the role of gender in the occurrence of CHD and the protective role of estrogen for the delayed occurrence of cardiac events in women.[18] The mean BMI of our participants was 24.75. Similarly in the Framingham offspring study, it was found that 72% of men and 42% of women had a BMI greater than or equal to 25.00.[19]

The relationship between regular physical exercise and protection from cardiovascular diseases has long been stressed. In our study, 84% of participants did not involve in regular physical exercise, 65% of participants were chronic smokers who smoked a minimum of three cigarettes per day for the past 10 years, 75% of them had hypertension and 48% of them had diabetes mellitus type II. Numerous earlier studies stressed the fact that the majority of patients with cardiac diseases have a minimum of one CHD -related risk factor like cigarette smoking, lack of exercise, diabetes mellitus, overweight, or hypertension.[20],[21]

Despite an increasing number of angioplasties performed in India most cardiology departments do not have a mental health component. This study highlights the importance of psychological factors in patients undergoing angioplasty. The change in QOL assessed by the MacNew questionnaire revealed that there was an overall improvement in QOL before and after angioplasty. A significant improvement in emotional and physical sub scales of quality of life was also observed but there was no significant improvement in the social sub scale [Table 5]. In a study, where the SF-36 questionnaire was performed before angioplasty, and one month after the procedure, an overall improvement in QOL in seven of the nine health domains was observed one month after angioplasty.[22] Our results are similar to that of an earlier study where the MacNew scale was used 2 days before and 3 months after angioplasty. A significant difference was observed in QOL before and three months post angioplasty.[23] In another study also, the QOL of patients who underwent angioplasty was re-evaluated 3, 6, and 12 months after the operation, and a significant improvement in QOL was observed.[24]

In another study, it was observed that the following angioplasty, there was a significant increase in QOL due to a reduction in stress, and it was also found that psychological factors such as depression, anxiety, and stress, were reduced in patients post revascularization procedures like angioplasty.[22]

Prevalence of type D personality among angioplasty patients

One out of four patients with CHD has Type D personality, characterized by two traits: Social inhibition and negative affectivity. In agreement with the above, amongst our study participants, 28.57 percentage had Type D personality. These results are also similar to an earlier study where in a total of 268 study participants were assessed and a total of 26% of them had Type D personalities. Social inhibition which is a component of Type D personality is shown to be an independent predictive factor for depression by multiple regression analysis in our study. These results are similar to that of a previous study where positive correlations between the total DS-14 score and the Becks Hopelessness Scale, (P = 0.024) were seen and scores on the SI subscale of DS-14 were more in the group with history of attempted suicide than in the group without the above history.[25],[26],[27],[28]

Assessment of depression, anxiety, and stress pre and post angioplasty

Our results show an overall improvement in depression, stress, and anxiety scores post angioplasty on the DASS-21 scale. These results are similar to that conducted by Chaudhury et al.[29] where in, it was observed that successful angioplasty resulted in a significant decrease in depression, anxiety, and physical limitation and an increase in disease perception and overall health status. Their analysis showed that among the study participants, 42% had significant anxiety and 32% had significant depression before angioplasty. After successful angioplasty, none of the patients had significant anxiety, and only two (3.6%) had significant depression. Our results are also similar to an earlier study where a total of one hundred and eight patients were assessed at the beginning of angioplasty and at six and twelve months after discharge. Results showed that symptoms of depression significantly reduced (P < 0.05) and subjective mental (P = 0.001) and physical health (P < 0.001) showed improvement over time.[30]

Strengths

One of the few Indian studies which compared both Quality of life and emotional factors pre and post angioplasty. One of the first Indian studies assessed the prevalence of Type D personality in patients undergoing Angioplasty.

Limitations

The sample size was modest and the follow-up was also short due to the prevailing pandemic.

Since the study was done at a tertiary care centre, it may not be representative of the population.


  Conclusion Top


Angioplasty is associated with significant improvement in anxiety, stress, emotional, and physical sub scales of Quality of life. The prevalence of Type D personality was 28.5% in our study population. Social inhibition, which is a component of Type D personality, anxiety, and loss of libido are significant predictors of depression in patients undergoing angioplasty. Attention to these factors may improve the quality of life of patients undergoing angioplasty.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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