The effect of physical, social and psychological factors on drug compliance in patients with mild hypertension.

BACKGROUND: In patients with hypertension noncompliance with drug treatment is between 15 to 54%, and has been recognised as a relevant contributor to the burden of cardiovascular morbidity. Up to 92% of patients experience unpleasant symptoms with their condition and, particularly in these patients, the symptoms experienced may enhance compliance. OBJECTIVE: To simultaneously assess the effects of physical, social and psychological factors on noncompliance. METHODS: Patients with mild hypertension despite drug treatment, from the departments of cardiology and internal medicine, were requested to answer a self-administered questionnaire addressing the presence of physical symptoms as well as psychosocial factors. The questionnaire was based on previously used test batteries and consisted of two lists of physical complaints and four lists addressing the four domains of planned behaviour regarding medical non-adherence according to Baron and Byrne. These domains mainly assess psychosocial factors. Each list consisted of three or more items and each item was scored on fiveto seven-point scales. Mean scores were used for assessment. The lists were also separately assessed for internal consistency and reliability using Cronbach's alphas. One-way analysis of variance and multivariate analysis of variance (MANOVA) with compliance as outcome variable and the physical, social and psychological variables as indicator variables were used for data analysis. MANOVA was adjusted for multiple testing. RESULTS: Many patients experienced physical symptoms due to hypertension, such as tiredness (31%), hot flushes (28%), headache (24%), reduced daily life energy (23%), palpitations (22%), with 95% confidence intervals between 16 to 38%. Scores for physical symptoms and social factors did not differ between self-reported adherers (n=165) and nonadherers (n=11). However, the score for psychological factors was significantly larger in the adherers than in the non-adherers, 5.05 versus 3.06, p<0.018. The MANOVA showed a significant overall difference between the adherers and non-adherers in the data at p<0.012, which was mainly due to the score for psychological factors. Conclusion. The effect of physical symptoms on non-compliance in mildly hypertensive patients is negligible. So is the effect of social factors. Psychological factors such as lacking a sense of guilt, regret and shame are major determinants of non-compliance. Physicians may play an educational role in improving their patients' compliance by addressing these determinants. We should add that the conclusions should be made with reservations, given the small number of non-adherers in our sample. (Neth Heart J 2008;16:197-200.).

Chronic nitrate therapy in patients with angina with comorbidity.

In a retrospective study from the Dutch Mononitrate Quality of Life (DUMQOL) Study Group, the authors found that patients with angina with concomitant diabetes or hypercholesterolemia derived more benefit from changing over to a once-daily nitrate treatment regimen than did patients without angina. The aim of this study was to assess this issue prospectively. In an open-label study, patients with stable angina pectoris from facilities in Germany, Portugal, and me Czech Republic were treated for 3 months with multiple daily doses and subsequently for 3 more months with once-daily isosorbide mononitrate/dinitrate. After the first and second 3-month periods, they were assessed by a validated QOL battery including domains for mobility, side effects, life satisfaction, anginal pain, and psychological distress. In the 1045 patients who participated in the study, the mean summary domain scores varied from 5 to 16 points and score improvements from 1.6 to 4.3 points. In the patients without concomitant hypertension and smokers, domain scores improved less than they did in the patients without, with differences in domain score improvements up to 1.0 points (P<0.001), which is substantial considering the range of improvement was between 1.6 and 4.3 points. In the patients with diabetes mellitus or hypercholesterolemia, a reverse pattern was observed with differences in domain score improvements up to 0.4 points (P<0.05). Patients with angina with diabetes or hypercholesterolemia derived more benefit from an asymmetric regimen of isosorbide mononitrate/dinitrate than did patients without. Patients with angina with hypertension and smokers benefited less. Differences in endothelial function may be involved.

Quality of life of patients on the waiting list for coronary angiography.

BACKGROUND: Providing adequate medical information and ensuring that patients do not identify with fellow-sufferers who are doing worse are significant contributors to a better quality of life (QOL) in cardiac patients. In addition, in these patients gender and the level of psychic tension are significant predictors of QOL. We do not know (1) whether we can improve QOL by increasing patients' ability to cope with the unpleasant aspects of the underlying condition, (2) whether gender and level of psychic tension interact or act independently. OBJECTIVE: To assess both questions. METHODS: Thirty-eight patients on the waiting list for coronary angiography were assessed with validated test batteries. To increase the patients' ability to cope, they were randomly assigned to read either (1) the comments of a patient who had previously been treated successfully or (2) general information. The former information, unlike the latter, was assumed to improve coping ability and, thus, provide better QOL. Homogeneity of the patient group was estimated by Cronbach's alphas. For analysis, linear regression and general factorial analyses of variance were applied. RESULTS: The group was psychologically homogeneous as indicated by Cronbach's alphas which were generally over 75%. There was a significant or close to significant association between the use of coping information and a better mobility and social performance QOL (p<0.05 and p<0.06). High levels of psychic tension were associated with low self-perceived QOL and low psychological scores (both p<0.02). Female gender was associated with lower mobility, lower psychological scores and lower overall QOL (p<0.05, p<0.02 and p<0.05). A significant or close to significant interaction was observed between gender and psychic tension as combined determinants of self-perceived QOL, mobility index, and overall QOL index (p<0.03, p<0.09, and p<0.05). Separate assessments of these determinants showed that female gender was the strongest determinant of a low QOL. CONCLUSION: In patients on the waiting list for coronary angiography, an increased ability to cope with the unpleasant aspects of a possible underlying heart condition improves QOL. Female gender and a high level of psychic tension place patients at risk for a low QOL. It is to be hoped that this paper will raise physicians' awareness of these psychological mechanisms and that they will be given adequate attention in the future, particularly in female patients.

Quality of life with heart failure: psychosocial determinants to be considered by cardiologists.

BACKGROUND: Independent determinants of QOL (quality of life) with heart disease have been recognised and include factors such as severity of medical condition, comorbidity, and concomitant medication. Psychosocial factors, as 'ability to cope with the unpleasantness of the medical condition', 'want of information', and 'social identification' have an important influence on self-perceived wellbeing, but their influence on health-related QOL domains and self-perceived QOL in patients with heart failure has not been systematically studied. OBJECTIVE: To assess correlation between such psychosocial factors and QOL in patients with heart failure. METHODS: Patients from the outpatient heart failure clinic of the Martini Hospital, a 1000-bed community hospital in the city of Groningen, the Netherlands, were included if their ejection fractions were <40% and their medical diagnosis according to their cardiologists was stable chronic congestive heart failure. The following QOL estimators were applied: Pearlin's Mastery Scale, Stewart's Short Form 36 Quality of Life Questionnaire, Dupuy's Index of Wellbeing, Cantrill's Self-perceived Quality of Life Scale, Mester's Want of Information Scale. Internal consistency of the multi-item scales was estimated by Cronbach's alphas. Linear and multiple linear regression analyses were performed of the data. RESULTS: Sixty patients were enrolled, 41 males and 19 females, average age 68 years (range 51 to 84 years). 'Ability to cope with the unpleasantness of the medical condition' was not only an independent determinant of self-perceived and health-related QOL (both p<0.001), but also of each domain of health-related QOL separately (p<0.001 for each domain). Lack of 'adequate medical information' and 'negative social identification' (identification with fellow-sufferers who are doing worse) were negative predictors of 'ability to cope' (p<0.01 and <0.001 respectively). 'Negative social identification' was also an independent determinant of self-perceived QOL, both unadjusted and after adjustment for 'ability to cope' and 'adequate medical information'. CONCLUSION: Relevant recommendations from this paper to be considered by cardiologists during everyday office hours could include: 1. Patients who express having difficulties in coping with the unpleasant aspects of their underlying heart condition have low health-related QOL as well as low self-perceived QOL. 2. Providing adequate medical information is a significant contributor to both better 'ability to cope' and better self-perceived QOL. 3. Avoiding identifying with fellow-sufferers who are doing worse and, instead, starting to identify with those who are doing better, are significant contributors to both better 'ability to cope' and better self-perceived QOL.

Psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q).

OBJECTIVE: To evaluate the psychometric properties of the Minnesota Living with Heart Failure Questionnaire (MLHF-Q) in patients with atrial fibrillation. DESIGN: A prospective study of the patients who underwent DC electrical cardioversion. SETTING: Clinics of cardiology and thoracic surgery of the University Hospital in Groningen, the Netherlands. MAIN OUTCOME MEASURES: The disease-specific MLHF-Q and generic measures of quality of life were administered. The sensitivity to change over time was tested with effect sizes (ES). Internal consistency of MLHF-Q scales was estimated with Cronbach's alpha. To evaluate the construct validity multitrait-multimethod analysis was applied. The 'known group validity' was evaluated by the comparison of mean scores and effect sizes between two groups of the New York Heart Association (NYHA) classification (NYHA I versus II-III). Stability of MLHF-Q scales was estimated in a subgroup of patients who remained stable. Perfect congruence analysis and factor analysis were applied to confirm the a priori determined structure. RESULTS: Cronbach's alpha was > or = 0.80 of the MLHF-Q scales. Perfect congruence analysis (PCA) showed that the results resemble quite well the a priori assumed factor structure. Multitrait-multimethod analysis showed convergent validity coefficients ranging from 0.59 to 0.73 (physical impairment dimension) and 0.39 to 0.69 (emotional dimension). The magnitude of change can be interpreted as medium (ES = 0.50). The results of a 'test-retest' analysis in a stable group can be valued as satisfactory for the MLHF-Q scales (Pearson's r > 0.60). The physical dimension and the overall score of the MLHF-Q discriminated significantly between the NYHA I and II-III groups (p < 0.001) with large effect sizes (ES > 1.0).

Left ventricular beat-to-beat performance in atrial fibrillation: contribution of Frank-Starling mechanism after short rather than long RR intervals.

OBJECTIVES: This study sought to evaluate control mechanism of the varying left ventricular performance in atrial fibrillation. BACKGROUND: Atrial fibrillation is characterized by a randomly irregular ventricular response, resulting in continuous variation in left ventricular beat-to-beat mechanical behavior and hemodynamic variables. METHODS: Fourteen patients with chronic nonvalvular atrial fibrillation were studied, using a nonimaging computerized nuclear probe linked to a personal computer. Left ventricular ejection fraction, end-diastolic and end-systolic volume counts, stroke volume counts and filling time were calculated on a beat-to-beat basis during 500 consecutive RR intervals. Multiple regression analysis was used to assess how ejection fraction was predicted by these variables. RESULTS: The preceding RR interval and end-diastolic volume showed a positive relation, and prepreceding interval and end-systolic volume an inverse relation, with ejection fraction (all p < 0.001). Sensitivity analysis suggested that the preceding interval and the end-diastolic volume were equally important in predicting ejection fraction. There was a relatively strong interaction between the preceding interval and end-diastolic volume, indicating that the influence of the end-diastolic volume on ejection fraction was diminished after long intervals. A second interaction showed that the effect of end-diastolic volume on ejection fraction was attenuated after short prepreceding cycles. CONCLUSIONS: Cycle length-dependent contractile mechanisms, including postextrasystolic potentiation and mechanical restitution, determine the varying left ventricular systolic performance during atrial fibrillation over the entire range of intervals. Beat-to-beat changes in preload, consistent with the Frank-Starling mechanism, also play a role, but their influence is diminished after long preceding and short prepreceding intervals.