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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 3  |  Issue : 3  |  Page : 113-121

Psychosocial and medical predictors of 1-year functional outcome in male and female coronary bypass recipients


1 Psychological Services, Langley, BC, Canada
2 Department of Psychology, University of British Columbia, Vancouver, Canada
3 Division of Cardiology, St Paul's Hospital and University of British Columbia, Vancouver, Canada
4 Australian Institute of Family Studies, Melbourne, Australia
5 Department of Psychology, University of Calgary, Calgary, Canada

Date of Submission08-Oct-2019
Date of Acceptance06-Nov-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. Wolfgang Linden
Department of Psychology, UBC, 2136 West Mall, Vancouver BC V6T 1Z4
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_64_19

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  Abstract 


Background and Purpose: This study examines coronary artery bypass graft (CABG) patients, their baseline medical and psychosocial characteristics, and level of functioning after 1 year. Functioning was defined as ability to play their role in social, family, recreational, and occupational areas. Sex differences and the buffering effect of social support were also investigated. Methods: This prospective, observational study recruited 296 (42% female) post-CABG patients, of whom 234 (79%; 44% female) had complete data at 1-year follow-up. Clinical and demographic variables were collected following surgery via chart review and provincial database. Depressive symptoms, perceived social support, household responsibilities, marital status, pain, and role interference were assessed at baseline and 1 year later. Hierarchical linear regression examined relationships between baseline psychosocial variables and 1-year role interference controlling for potential medical confounding variables. Results: One-year role interference was partially predicted by baseline depression, social support, household responsibilities, and marital status (R2 = 0.20,P < 0.001), but not disease severity. Baseline depression predicted 1-year role interference only at mean (b = 0.15, 95% confidence interval [CI] [0.01, 0.31]) and high (b = 0.30, 95% CI [0.12, 0.48]) perceived social support. Baseline perceived social support predicted greater reduction in 1-year role interference in women compared to men (interaction b = 0.29; 95% CI [0.06, 0.52]) and reduced the association between high depression symptoms and role interference in women only (b = −0.25, 95% CI [−0.42, −0.09]). Conclusions: Long-term role interference in bypass graft recipients was not associated with disease severity, but was predicted by social variables and depressive symptoms. In women perceived social support moderated the association between depression and role interference.

Keywords: Coronary artery bypass graft, functional outcome, postoperative pain, psychosocial characteristics, role interference


How to cite this article:
Young S, Linden W, Ignaszewski A, Con A, Terhaag S, Campbell T. Psychosocial and medical predictors of 1-year functional outcome in male and female coronary bypass recipients. Heart Mind 2019;3:113-21

How to cite this URL:
Young S, Linden W, Ignaszewski A, Con A, Terhaag S, Campbell T. Psychosocial and medical predictors of 1-year functional outcome in male and female coronary bypass recipients. Heart Mind [serial online] 2019 [cited 2022 Dec 9];3:113-21. Available from: http://www.heartmindjournal.org/text.asp?2019/3/3/113/272082


  Introduction Top


Background and rationale

Given excellent survival rates after first myocardial infarction (MI),[1] clinical practice and research increasingly focus on rehabilitation, aiming to restore function and quality of life. Rehabilitation activities and concerns vary as patients move along the recovery trajectory. The first few months of care after a cardiac event or surgery focuses on medical stabilization and physical rehabilitation. In the next phase, health behaviors may change, and return to premorbid function becomes the next target. Although coronary artery bypass graft (CABG) surgery aims to decrease pain, increase function, and extend patient's lives, for some, physical and psychological concerns continue over long-term follow-up.[2] Ongoing cardiac symptoms that still exist even after structured cardiac rehabilitation, may interfere with the ability to function well in multiple roles such as family, work, social, and recreational. Functioning well in these multiple roles is critical to perceived quality of life and serves as a proxy for cardiac health in the eyes of patients themselves.[3],[4]

These observations stimulate the question of which variables allow prediction of role functioning after 1 year and which should therefore receive tailored attention in cardiac rehabilitation programs. Among the hypothesized predictor variables, the relationships among pain and physical function, along with depression and social support, have been investigated previously. Further, although depression and social support are related to later pain and physical function,[5],[6],[7],[8] few studies have prospectively assessed medical and psychosocial predictors of long-term cardiac symptom interference in family, occupational, social, and recreational roles (with the notable exception of Sullivan).[9] Aside from reflecting an obviously desirable high quality of life, quick recovery of function and accelerated return to work save money to health insurance careers and the larger economy. Consequently, the present study sought to study CABG recipients and their measurable characteristics that might be predictors of successful return to high premorbid levels of function in occupational and social areas.

Psychological characteristics, social environment, and adjustment

Depression is the most studied singular predictor of post-CABG adjustment[10] and carries a 2:1 independent risk for subsequent mortality.[11] This is important because the point prevalence of depression is elevated before and after CABG surgery (20%–30%).[11] Depression may raise cardiac risk through increased inflammation;[12] endothelial, autonomic, and hypothalamic–pituitary–adrenal axis dysfunction;[13],[14] decreased medication adherence;[15] increased dropout from cardiac rehabilitation;[16] and impaired postoperative self-management.[17] Further, post-CABG, patients with elevated depression symptoms report greater pain and decreased physical function[5],[6],[7] and are less likely to return to work.[18] Perceived social support has also been related to lower physical function post-MI.[8] Despite known associations between social support and mood, and the stress buffering effect of social support,[19] few studies acknowledge that depression may be moderated by the patient's social resources. The combined influence of depression and social factors on how individuals function in important roles after CABG has not been investigated previously, and filling this void is the goal of the present study.

Sex differences

Sex differences are pervasive in CABG outcomes, psychosocial variables, and rehabilitation.[20] Post-CABG surgery, women experience higher mortality, more pain, complications, and physical impairment;[20],[21] they also drop out of cardiac rehabilitation at higher rates than men.[16] Surrounding CABG surgery, women experience more depressive symptoms than men,[10] report lower social functioning,[22] and due to their older age at CABG, are less likely to be married.[23] Sex differences are also supported in other cardiac populations.[20] Following an MI, women report lower perceived social support, lower assistance from spouses, and less help with household duties than men.[24] Depressive symptoms may also differ for women. In a cardiac population, women reported more fatigue-related depressive symptoms than men.[25] Furthermore, activity in the home and its association with outcome may reflect a sex role variable because women spend more time on household activities after CABG surgery and experience significantly greater stress due to these activities.[26] Psychosocial factors, in particular depression, perceived social support, and marital status, likely form a cluster of factors that impact long-term cardiac rehabilitation and should be studied together while simultaneously recognizing consistently reported sex differences in these variables. Given these sex differences, sex-specific analyses are urgently called for, but only infrequently undertaken.[27]

In summary, social environmental factors and depression may affect cardiac outcomes differently in men and women. However, to date, research has not clarified how depression and social variables combine and interact to predict differential outcomes after CABG surgery among men and women.

This prospective, observational study examined predictors of 1-year role interference after CABG surgery with a focus on sex differences. We hypothesized that (1) postoperative depressed mood, low perceived social support, lack of a partner, and high household responsibilities would independently predict role interference 1 year post-CABG surgery over and above traditional medical risk predictors; (2) both structural and functional support would be associated with outcomes following CABG surgery and explain variance in role interference over and above depression; (3) perceived social support would buffer the association of depression with outcome; and (4) these relationships would differ by sex. Postoperative pain tends to decrease quickly after surgery, and angina (and related pain) is usually treated until disappearance. When present, however, it correlates highly with role interference (r = 0.65 at 1-year postbypass in our sample). Given that role interference is a broader, more comprehensive construct, and to avoid redundancy, this study therefore focuses on role interference as the primary outcome and avoids a focus on pain.


  Methods Top


Participants

Two hundred and ninety six patients were recruited after first CABG (male = 171, female = 125; age: 36–88 years) within a Canadian cardiac center [Figure 1]. At 1-year post-CABG, 234 complete questionnaires were available for analysis (79.0%; male = 133, female = 101). Of 438 patients initially approached, 67.6% participated at baseline and 53.4% had complete questionnaires at 1 year. Compared to a representative sample of patients on CABG waitlists in British Columbia from 1991 to 2000,[28] our sample has more women (43.4% compared to 17.7%) and consequently, a lower proportion under 60 years of age (23% vs. 30%; 95% confidence interval [CI] (0.18, 0.29); binomial test = −2.01, standard error [SE] =7.0, P = 0.02).
Figure 1: Flow diagram of participants through the study process over 12 months

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Participants were at least 18 years of age, undergoing first CABG surgery, at a major cardiac center, and still in hospital following CABG surgery. Exclusion criteria were developed to ensure that participants were able to participate in informed consent, complete questionnaires with minimal assistance, and minimize strain which might interfere with patient recovery. Research assistants assessed exclusion criteria through examination of chart notes and discussions with nursing staff and patients and comprised the following: presence of serious medical problems (unstable vital signs, angina recorded in the last 12 h, and complicated course following surgery) and inability to discuss informed consent or complete questionnaires independently (deaf, hard of hearing, blind, or having insufficient ability to comprehend, read, and/or speak English; mental illness/behavioral disorder including anxiety, extreme distress, hostile or negative affect; or exhibiting neurological deficits).

Procedures

Two trained research assistants approached participants on the ward from day 2 until discharge after a first CABG ± valve surgery (17.4% with valve procedure). The mean time to completion for baseline questionnaires was 8.9 days following surgery (standard deviation [SD] = 9.8; range = 2–77). The patients completed questionnaires independently and left them in a labeled envelope at the nursing station at discharge. Recruitment continued until 125 women enrolled. Standardized questionnaires assessed depressive symptoms, perceived social support, household responsibilities, marital status, pain severity, and role interference. Baseline medical and surgical variables were obtained from hospital charts and Cardiac Services BC, a provincial registry which maintains a database to assist with cardiac services planning, coordination, monitoring, evaluation, and research.[29] One-year post-CABG surgery, participants were mailed a second questionnaire package, repeating the original questionnaires and asking about activities since surgery. The mean completion time for follow-up questionnaires was 393.2 days following surgery (SD = 41.2; range = 317–663). All participants provided written informed consent, and the research was approved by local ethics boards.

Measures

The Risk Score for Predicting Long-Term Mortality After CABG Surgery, based on the New York State Cardiac Surgery Reporting System (NYLT), has well-demonstrated predictive validity for cardiac mortality[30] and was chosen to adjust analyses for baseline cardiac disease severity. NYLT score is a sum of weighted-item subscores for baseline: age, body mass index, ejection fraction, hemodynamically unstable or shock, left main coronary artery disease (CAD), cerebrovascular disease, peripheral arterial disease, congestive heart failure, malignant ventricular arrhythmia, chronic obstructive pulmonary disease, diabetes, renal failure, and previous open-heart operations. Missing risk factors (except for left ventricular ejection fraction) were coded as “no.”

The West Haven-Yale Multidimensional Pain Inventory (WHYMPI)[31] was used to assess pain and its interference with patient's daily roles, regardless of physical function. The WHYMPI is a widely used multidimensional inventory, previously used in a cardiac population.[9] Two of the 12 subscales were utilized in this study: pain severity (3 items) and role interference (9 items), with good internal consistency (Cronbach's α = 0.91 and 0.80). Scores on both subscales range from 0 to 6, with higher numbers indicating greater pain or role interference. The role interference subscale measures perceived pain interference “… in family and marital functioning, work and work-related activities, and social-recreational activities”[31] (p347). Role interference reported at 1-year post-CABG served as our outcome, adjusted for presurgery role interference retrospectively reported following surgery. We also chose to assess depressive symptoms, given their association with poor quality of life following CABG surgery.[7] Patients completed the Beck Depression Inventory (BDI),[32] a widely used and validated measure of depression. It has demonstrated acceptable sensitivity (83.8) and specificity (71.7) to detect a diagnosis of depression in patients recently experiencing an MI[33] and is also a validated measure of depression in older individuals, such as those in the current sample.[34] The BDI had good internal consistency in this sample (Cronbach's α = 0.85). Being married, defined as living with a marital or common-law partner, was used as an indicator of structural support, while the Interpersonal Support Evaluation List (ISEL) measured overall perceived social support.[35] ISEL scores ranged from a low of 0 to a high of 10. The ISEL is a widely used measure and has concurrent validity with other measures of social support.[36] It exhibited good internal consistency in this sample (Cronbach's α = 0.88). The household responsibilities subscale (15 items) of the Marital Roles Questionnaire (MRQ) assessed patient participation in: housework, repairs, cooking, and paying bills.[37] Responses were modified to obtain an overall score indicating patient household responsibility coded as follows: 2 = done primarily by patient, 1 = done with spouse or others, and 0 = mainly done by spouse or others. This transformation permitted completion by individuals living alone and showed good internal consistency in our sample (Cronbach's α = 0.86).

Statistical analysis

All participants with complete 1-year post-CABG follow-up questionnaires were included in the analyses. For questionnaire subscales missing ≤25% of responses, missing items were replaced with the participant's subscale mean. Individuals with subscales missing >25% of items (3% of this sample) were excluded from the analyses given they were equally distributed among men and women, represented a small proportion of the sample, and were considered missing at random.[38]

Given our interest in sex differences, Mann–Whitney U-test and Chi-square test, as appropriate, were conducted by sex to describe unadjusted differences in baseline variables among men and women. We investigated univariate relationships among predictor variables and 1-year pain and role interference with Pearson's correlations, or Spearman's rho, for dichotomous variables. Finally, ordinary least squares multiple regression tested adjusted associations between baseline psychosocial variables and 1-year role interference. Given heteroscedasticity in predictor variables, heteroscedasticity-consistent estimators and bootstrapping were used to reduce bias in SEs and confidence intervals.[39] Prior to regression, all variables were standardized to z-scores (with mean = 0 and SD = 1) to produce regression coefficients describing the SD change in 1-year role interference due to a one SD increase in predictor. Hierarchical forced entry regression investigated the additional explanatory power of social variables over depressive symptoms. Block one included sex, baseline role interference, disease severity (NYLT), smoking status at surgery, and cardiac rehabilitation participation; block two: depression symptoms; block three contained social variables: perceived social support, marital status, and household responsibilities; and interactions were tested in block four. Predictor variables were retained regardless of significance. One-tailed tests assessed predictors with prior directional hypotheses (BDI, ISEL, Marital Status, MRQ, and NYLT), with P < 0.05 considered statistically significant. Significant interactions were explored with simple slopes, estimated at levels of dichotomized variables or, in the case of continuous variables, at the mean and one SD above and below the mean. Analyses were conducted using (IBM Corp, 2012, SPSS, Statistics for the Social Sciences, version 21.0, Armonk, NY).


  Results Top


Patient characteristics by sex

Sample characteristics by sex are presented in [Table 1]. Although an equal proportion of men and women reported experiencing any role interference prior to CABG surgery, a higher proportion of women reported role interference by 1-year following surgery. At both times, women reported higher mean role interference scores, but not greater pain. Women reported higher mean depressive symptoms and household responsibilities at both times and lower perceived social support at 1-year. Baseline-only participants differed from 1-year post-CABG participants in one respect: women had higher baseline disease severity compared to male participants (U (294) = 8932.0, Z = 2.42, P = 0.015), while this was equal in 1-year completers.
Table 1: Characteristics of complete participants according to sex

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Unadjusted relationships

Correlations investigated unadjusted relationships among predictor and outcome variables [Table 2]. At baseline, higher depression was moderately related to lower social support and greater household responsibilities, whereas social support was unrelated to household responsibilities. Both higher baseline depression symptoms and lower baseline perceived social support were moderately associated with greater 1-year pain and role interference. Married participants reported significantly lower household responsibilities. Finally, a high correlation existed between 1-year cardiac pain and role interference (shared variance = 42%), leading to the decision to use only the broader construct of role interference as an outcome to be predicted.
Table 2: Intercorrelations of baseline measures with 1-year postcoronary artery bypass graft role interference and pain

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Multiple regression

As can be seen in [Table 3], only baseline role interference was related to one-year post-CABG role interference (P=.001, R2=.01. In block two, after adjustment, higher baseline depression symptoms predicted greater one-year role interference (ΔR2 =.01, P=.049). Block three (ΔR2 =.07, P =.004) revealed greater perceived social support, household burden and being married were all related to lower role interference, and depression symptoms were no longer associated with outcome. In the final model (ΔR2 =.04, P =.01) significant interactions of depression symptoms x perceived social support and perceived social support x sex significantly explained 3.0% and 1.6% of the variance in an overall model accounting for 19.8% of the variance in one-year role interference (medium effect size, f2 =.16). No other two or three-way interactions with sex were significant (all P >.20). Significant interactions are interpreted in the following section.
Table 3: Linear model of baseline predictors of 1-year postcoronary artery bypass graft role interference

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Analysis of simple effects

Simple effect analysis of the depression symptoms × perceived social support interaction indicated a 6.8 unit (one SD) increase in baseline depression symptoms, which was associated with 0.41-unit increase in 1-year role interference at high perceived social support (ISEL = 9.9; b = 0.30, P = 0.007, 95% CI [0.12, 0.48]) and a 0.20-unit increase in role interference at mean perceived social support (ISEL = 8.6; b = 0.15, P = 0.027, 95% CI [0.01, 0.31]), but no association at low perceived social support (ISEL = 7.4; b = 0.01, P = 0.876, 95% CI [−0.12, 0.15]). An overall buffering role of perceived social support on the relationship between baseline depression symptoms and 1-year role interference was not supported [Figure 2].
Figure 2: Predicted 1-year role interference by baseline depression symptoms and perceived social support for men and women

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Given concurrent, significant perceived social support × sex and depression symptoms × perceived social support interactions, the association between baseline perceived social support and 1-year outcome had to be analyzed at levels of baseline depression symptoms and sex. For men, a 1.3-unit (one SD) increase in perceived social support was associated with a 0.34-unit decrease in 1-year role interference at low baseline depression (BDI = 2.2; b = −0.25, P = 0.037, 95% CI [−0.47, −0.02]), but was not associated with outcome at mean (BDI = 9.1; b = −0.11, P = 0.34, 95% CI [−0.30, 0.08]) or high depressive symptoms (BDI = 15.5; b =0.03, P = 0.81, 95% CI [−0.17, 0.22]). After adjustment for baseline role interference, disease severity (NYLT), smoking status at surgery, and cardiac rehabilitation participation, higher perceived social support was only associated with better role function when men reported low depressive symptoms (ES = 0.25). For women, a 1.3-unit (one SD) increase in baseline perceived social support was associated with decreased 1-year role interference at all levels of baseline depression: low (BDI = 2.2; b = −0.53, P < 0.001, 95% CI [−0.74, −0.32]; 0.72-unit decrease in role interference), mean (BDI = 9.1; b = −0.40, P < 0.001, 95% CI [−0.56, −0.23]; 0.54-unit decrease in role interference), and high (BDI = 15.5; b = −0.25, P = 0.009, 95% CI [−0.42, −0.09]; 0.34-unit decrease in role interference). After adjustment for baseline role interference, disease severity (NYLT), smoking status at surgery, and cardiac rehabilitation participation, in women with high, mean, and low levels of depressive symptoms, higher perceived social support was related to reduced 1-year role interference and perceived social support exhibited larger effects on 1-year role interference in women than men.


  Discussion Top


The objective of this research was to identify predictors of poor long-term function (i.e., role interferences) in post-CABG patients. We intentionally did not focus on mortality as an outcome because at 1 year post-CABG, the mortality base rates are (fortunately) very low. Return to function is, however, an important and desired outcome for all patients. If changeable predictors of return to function can be identified early (i.e., before even being released from hospital), staff can better know specific rehabilitation needs and tailor treatments accordingly. As such, the most important finding was that a very comprehensive medical risk indicator and traditional medical risk factors did not explain 1-year level of function in key life roles of patients. However, after adjusting for sex and clinical risk, depressive symptoms explained additional variance in long-term role interference, with social variables adding further explanatory power. Not being married, reporting low household responsibilities, low perceived social support, and more depression symptoms following CABG surgery were associated with the greatest role interference at 1-year post-CABG.

Although an interaction between perceived social support and depression was supported, our overall buffering hypothesis for perceived social support moderating depression was not. Unexpectedly, reporting higher levels of depressive symptoms after CABG surgery was only associated with greater 1-year role functional impairment at average or higher levels of perceived social support. When perceived social support was low, 1-year role interference was high and it did not matter if depression symptoms were low or high; an increase in depression symptoms did not additionally increase role interference. Furthermore, in women, greater perceived social support predicted reduced 1-year role interference, even when depressive symptoms were high, but this was not the case for men. For men, having either high depressive symptoms or poor perceived social support predicted lower 1-year role function. For women, although high depressive symptoms were associated with greater 1-year role interference, low perceived social support increased interference even further, with the highest interference in those women with low social support, regardless of depressive symptoms. Perceived social support may be equally as important as depressive symptoms in predicting functioning following recovery, especially in women, and this may be due to its relationship with health behaviors.[40] Although previous literature has associated post-CABG depression with later physical impairment,[5],[6],[7] these studies did not additionally investigate social support as we did, and our outcome was role functioning, which has not been previously investigated post-CABG. Perceived social support has also not been previously investigated in role functioning post-CABG surgery, but our results are consistent with research in patients recovering from MI. In that study, social support was related to quality of life during the year after recovery from an MI, and more strongly for women as we found here.[8] In our sample, greater perceived social support improved function in women with depressed mood, but not in men. Social support may play a greater role in buffering stress responses in women than men.[41] According to Taylor's theory, from an evolutionary perspective, affiliating with a social group may have developed as an adaptive strategy to increase physical safety in women and may consequently play a greater role in women's stress responses. Thus, even the perception of having social support may increase the thoughts of safety, allowing women to feel more comfortable about participating in roles following surgery.

Cardiac symptom interference in social, family, recreational, and occupational roles being associated with perceived social support and having a marital partner may be explained by the Social Control Theory. This posits that social support may help regulate or constrain behaviors.[40],[42] Being married and having higher perceived social support at the time of CABG surgery may increase participation in healthful activities, which could result in less role interference. Additionally, having a live-in partner may provide much-needed assistance, allowing patients to participate in these activities.

We also expected household responsibilities to be associated with poorer function, particularly in women. Contrary to our expectations, greater household responsibility at baseline, which we had hypothesized to be sex specific and reflective of increased stress for women,[26] is associated with less 1-year role interference for both men and women. Greater perceived household responsibilities may indicate better functioning prior to surgery and while admittedly speculative, may act as a desired activity in that it reflects a sense of meaning and greater self-efficacy,[24] in addition to being helpful in increasing physical activity which may be useful in rehabilitation.

Our results suggest that depressive symptoms and social support following surgery are associated with how patients function after recovery. Perceived and structural support during recovery may allow patients, even women with greater depression symptoms, to better function in social, family, recreational, and occupational areas following recovery. High levels of functioning well may act as part of a cycle, encouraging more activity and social contact, thus positively impacting rehabilitation and possibly long-term outcomes.

Strengths

The present study builds on the existing literature by revealing interactive relationships between social support, depression, and sex predicting 1-year post-CABG function. Although the goal of CABG surgery is to decrease pain and improve patient function, little previous research has investigated post-CABG role interference. Further, our recruitment of a high proportion of women provided adequate statistical power to investigate sex differences.

Limitations

Our effort to oversample women did not allow for consecutive recruitment, but permitted the desired balance in sample size for both sexes, allowing investigation of sex differences. Further, our exclusion criteria biased our sample in favor of a healthier subset of patients undergoing CABG surgery, thus the results of this study only apply to healthier patients. Because the most gravely ill patients were not retested, we cannot be certain that disease severity did not add to the explained variance in 1-year life function. Examining the causes of attrition [Figure 1] suggests that the more frail patients at baseline dropped out. However, this is a natural consequence of longitudinal studies based on patient samples, and the overall attrition was low (7%). Given this sample contained patients experiencing both isolated CABG surgery and CABG combined with valve surgery, patient heterogeneity may be higher.[43] This was necessary to retain sufficient statistical power, and as only 17.4% had valve surgery, we thought the heterogeneity to be acceptable and more representative of typical revascularization populations. Finally, given the stress of cardiac surgery, our assessment of depression following CABG surgery may have included distress related to surgery. Ideally, assessment would have to be conducted prior to a diagnosis of CAD to capture the effects of depression untainted by the stress of surgery and diagnosis, but this would require a much larger sample and lengthier follow-up, which we did not have.

Key findings

Remarkably, medical factors did not predict long-term role interference in bypass patients, whereas depression and social support were significant predictors. Perceived social support was more strongly related to later role interference for women and even decreased role interference in women with high depressive symptoms. Therefore, monitoring (and treating where necessary) psychological distress and modifiable social factors, such as social support, during the rehabilitation phase, is highly recommended. Merely monitoring and intervening on medical and pharmacological processes does not suffice to maximize patient rehabilitation.

Financial support and sponsorship

This study was financially supported by an operating grant from the BC and Yukon Heart and Stroke Foundation awarded to Wolfgang Linden.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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