Predictors of health-related quality of life in outpatients with coronary heart disease.

Introduction: Health-related quality of life (HRQoL) is an important treatment target in patients with coronary heart disease (CHD) and is associated with poor outcomes. Therefore, it is of clinical importance to identify the key determinants of HRQoL among these patients. There is, however, limited knowledge of how a comprehensive set of psychosocial factors influence HRQoL. We aimed to determine the relative associations of clinical and psychosocial factors with mental and physical components of HRQoL in a sample of CHD outpatients. Methods: This cross-sectional study included 1,042 patients 2-36 (mean 16) months after a CHD event recruited from two general Norwegian hospitals with a combined catchment area making up 7% of the Norwegian population, representative with regards to demographic and clinical factors. We collected data on HRQoL, demographics, comorbidities, coronary risk factors, and psychosocial factors. HRQoL was assessed using the Short Form 12 (SF12), which comprises a Mental Component Scale (MCS), and the Physical Component Scale (PCS). Crude and multi-adjusted linear regression analyses were used to investigate the association between covariates and MCS and PCS. Results: Mean age was 61 [standard deviation (SD) 10] years, 20% were females, 18% had type D personality, 20% significant depression symptoms, 14% significant symptoms of anxiety whereas 45% reported insomnia. The presence of type D personality (ß: -0.19), significant symptoms of depression (ß: -0.15), and the presence of insomnia (ß: -0.13) were negatively associated with MCS, but not PCS in multi-adjusted analyses. The presence of chronic kidney disease (ß: -0.11) was associated with reduced MCS, whereas the presence of chronic obstructive pulmonary disease (ß: -0.08) and low physical activity (ß: -0.14) were negatively associated with PCS. Younger age was associated with lower MCS, whereas older age was associated with lower PCS. Discussion: We conclude that Type D personality, depressive symptoms, insomnia, and chronic kidney disease were the strongest determinants of the mental component of HRQoL. Assessing and managing these psychological factors among CHD outpatients may improve their mental HRQoL.

Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up.

STUDY OBJECTIVES: Insomnia is highly prevalent and associated with anxiety and depression in patients with coronary heart disease patients. The development of effective psychological interventions is needed. Worry and rumination are potential risk factors for the maintenance of insomnia, anxiety, and depression that may be modified by psychological treatment grounded in the Self-Regulatory Executive Function model. However, the relationships between worry, rumination, anxiety and depression, and insomnia are not known. Therefore, we investigated these relationships both cross-sectionally and longitudinally among patients with coronary heart disease. METHODS: A cross-sectional study consecutively included 1,082 patients in 2014-2015, and 686 were followed up after mean of 4.7 years. Data were gathered from hospital records and self-report questionnaires comprising assessment of worry (Penn State Worry Questionnaire), rumination (Ruminative Responses Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and insomnia (Bergen Insomnia Scale). RESULTS: Insomnia correlated moderately with all other psychological variables (R 0.18-0.50, all P values < .001). After adjustments for anxiety and depression, odds ratios for insomnia at baseline were 1.27 (95% confidence interval 1.08-1.50) and 1.60 (95% confidence interval 1.31-1.94) per 10 points increase of worry and rumination, respectively. Corresponding odds ratios for insomnia at follow-up were 1.28 (95% confidence interval 1.05-1.55) and 1.38 (95% confidence interval 1.09-1.75). Depression was no longer significantly associated with insomnia after adjustments for worry and rumination, but anxiety remained significant. CONCLUSIONS: Worry and rumination predicted insomnia both cross-sectionally and prospectively, even after controlling for anxiety and depression, although anxiety remained significant. Future studies may test psychological interventions targeting these factors in patients with coronary heart disease and insomnia. CITATION: Frøjd LA, Papageorgiou C, Munkhaugen J, et al. Worry and rumination predict insomnia in patients with coronary heart disease: a cross-sectional study with long-term follow-up. J Clin Sleep Med. 2022;18(3):779-787.

Insomnia as a predictor of recurrent cardiovascular events in patients with coronary heart disease.

Study Objectives: Insomnia is highly prevalent in patients with coronary heart disease (CHD). However, the potential effect of insomnia on the risk of recurrent major adverse cardiovascular events (MACE) remains uncertain. Methods: This prospective cohort study included 1082 consecutive patients 2-36 (mean 16) months after myocardial infarction and/or coronary revascularization. Data on clinical insomnia, coronary risk factors, and comorbidity were collected at baseline. Clinical insomnia was assessed using the Bergen Insomnia Scale (BIS). The primary composite endpoint of MACE (cardiovascular death, hospitalization due to myocardial infarction, revascularization, stroke, or heart failure) was assessed with an average follow-up of 4.2 (SD 0.3) years after baseline. Data were analyzed using Cox proportional hazard regression models stratified by prior coronary events before the index event. Results: At baseline, mean age was 62 years, 21% were females, and 45% reported clinical insomnia. A total of 346 MACE occurred in 225 patients during the follow-up period. For clinical insomnia, the relative risk of recurrent MACE was 1.62 (95% confidence interval [CI]: 1.24-2.11, p < .001) adjusted for age, gender, and previous coronary events. In a multi-adjusted analysis, including coronary risk factors, cardiovascular comorbidity, symptoms of anxiety, and depression, the relative risk was 1.41 (95% CI: 1.05-1.89, p = .023). Clinical insomnia accounted for 16% of the MACE in attributable risk fraction analyses, being third in importance after smoking (27%) and low physical activity (21%). Conclusions: Clinical insomnia was associated with increased risk of recurrent MACE. These results emphasize the importance of identifying and managing insomnia in CHD outpatients.

Insomnia in patients with coronary heart disease: prevalence and correlates.

STUDY OBJECTIVES: The aim of this study was to determine the prevalence of insomnia and its association with clinical and psychosocial factors in a large sample of outpatients with coronary heart disease. METHODS: The sample comprised 1,082 patients, mean age 62 years (21% female), who participated in the cross-sectional NORwegian CORonary Prevention Study. Patients who were hospitalized with myocardial infarction and/or a coronary revascularization procedure in 2011-2014 responded to a self-report questionnaire and participated in a clinical examination with blood samples 2-36 (mean, 16) months later. Insomnia was assessed using the Bergen Insomnia Scale, a questionnaire based on the criteria for the clinical diagnosis of insomnia as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth version. We performed bivariate logistic regressions for crude analysis and backward stepwise logistic regressions for multiadjusted odds ratios (OR). RESULTS: In total, 488 patients (45%) reported insomnia, and 24% of these patients had used sleep medication in the previous week. Anxiety symptoms (OR: 5.61) were the strongest determinants of insomnia, followed by female sex (OR: 1.88), diabetes (OR: 1.83), eating fish fewer than three times a week (OR: 1.69), type D personality (OR: 1.69), and C-reactive protein ≥ 2 mg/L (OR:1.58), in multiadjusted analyses. CONCLUSIONS: Insomnia was highly prevalent in coronary heart disease outpatients. Psychological factors, lifestyle factors, and subclinical inflammation were associated with insomnia. Our results emphasize the need to identify patients with insomnia and provide appropriate management of insomnia in outpatients with coronary heart disease.