Track topics on Twitter Track topics that are important to you
The study is designed to test the hypothesis that participation in a standard phase III group based cardiac rehabilitation programme will improve psychological morbidity, quality of life and cardiovascular risk factors, along with chest pain severity and frequency in women with cardiac syndrome X.
Very few clinicians treating patients with Syndrome X could dispute that despite an excellent prognosis, the debilitating symptomology and ineffective treatment regimes typical in this condition give patients a miserable quality of life. First identified by Kemp (1), the triad of angina pectoris, a positive exercise test for myocardial ischemia and angiographically smooth coronary arteries continues to perplex clinician seeking a useful treatment regime.
The possible pathophysiology of chest pain associated with Syndrome X is poorly understood in these patients. Suggested mechanisms include abnormal myocardial flow reserve due to coronary microvascular dysfunction (‘microvascular angina’) (2) or a generalised disorder of vascular function (3),(4) early signs of abnormal left ventricular function (5), which in some patients may deteriorate over time,(6) and abnormal visceral pain perception (7). Some patients exhibit insulin resistance (8). However, there have been few adequate systematic explorations of the psychological and social aspects of Syndrome X.
Several studies have found increased levels of anxiety in patients with normal or near normal coronary arteries in the presence of accompanying chest pain (9). Ruggeri et al (10) found higher level of neuroticism and anxiety in small group of patients with Syndrome X in comparison with patients with confirmed coronary artery disease. Panic disorders, sometimes associated with chest pain, are also often presented with depression, hypochondriasis or other somatoform disorders (11). Studies investigating various non-therapeutic treatment regimes have repeatedly shown that relaxation and stress reduction lead to fewer incidence of chest pain in Syndrome X patients (12). However, the same is also true for patients with CAD (13) along with many other conditions and disorders with related chronic pain (14).
Frequency and severity of chest pain has been shown to have a direct effect on quality of life in Syndrome X patients (15). Sand (16) found that over a 7-year follow-up, a higher percentage of Syndrome X patients had given up work, reduced their daily activities and reported worsening chest pain in comparison to patients with confirmed coronary disease. Persistent functional incapacity with concomitant high levels of chest pain in patients with normal or near normal coronary arteries was also found after an 11-year follow-up (9). Use of anti-anginals was higher, as was their self reported burden on the health service.
The Collins team recently performed the largest psychosocial investigation of postmenopausal women with Syndrome X ever undertaken (17). The Hearts and Minds Study, which involved 100 Syndrome X patients, 100 patients with CHD and 100 healthy volunteers found that Syndrome X patients suffered significantly higher levels of anxiety than CHD patients or healthy controls. A greater number of Syndrome X patients suffered clinical levels of anxiety and depression than CHD patients and healthy volunteers, along with suffering significantly higher levels of psychological suffering as measured by the Health Anxiety Questionnaire than healthy controls. We also found that Syndrome X patients with a small social network had higher levels of anxiety than their counterparts with a larger social support structure.
In order to address these findings, it is important to identify an intervention which not only reduces anxiety, but also promotes wellbeing, improves quality of life and augments the social support resource network available to Syndrome X patients. Cardiac Rehabilitation (CR) has consistently been shown to improve the psychological wellbeing in cardiac patients, as recent reviews have highlighted the beneficial effects of CR on symptoms of angina and dyspnoea, stress level and psychological functioning (18). CR has been shown to have a positive affect on reducing anxiety levels in cardiovascular patients (19), while high levels of depression, a frequent co-morbidity in MI patients, have been reduced by CR (20). Women in particular seem to gain most benefit from CR, as improvements in functional capacity, coronary risk and psychosocial wellbeing were equal or greater in women than men following rehabilitation (21). It has been suggested that CR may reduce anxiety in CHD patients by reducing uncertainty, providing patients with an optimistic yet realistic outlook of recovery, as well as providing psychological support and promoting coping (18). Few could argue that a similar outcome in Syndrome X patients would not be beneficial.
As well as promoting psychological wellbeing, CR also provides patients with a social support resource network. The adequacy of social support has been investigated in relation the prognosis of patients with CHD (22) when it was noted that inadequate tangible support was a significant predictor of both morbidity and mortality. Population based studies have consistently identified a link between social support and CHD morbidity and mortality in men, while disease severity and proliferation have been shown to be related to a lack of support in women (23). Epidemiological studies have also consistently found a link between depression, social isolation and predicted morbidity and mortality in CAD patients (24). It has been argued that CR provides the social context through which coronary prevention interventions are delivered (25) and that this extra social support may have an important part to play in the patients recovery from, and adaptation to, chronic illness (26).
The effect of exercise intervention on the frequency and severity of angina has been the object of investigation for many years. Some studies have reported a reduction in mean weekly episodes of angina of up to 91% using an acute exercise intervention in CHD patients (13) and while other studies have been unable to replicate such results, almost all highlight the beneficial effect of exercise on angina frequency. Nevertheless, very few studies have investigated the impact of exercise on Syndrome X, either from a psychosocial or physiological view-point. Erikkson et al (27) addressed the physical deconditioning apparent in many Syndrome X patients through the use of 8 weeks moderate intensity exercise. Time to pain improved dramatically, with no increase in maximum pain experienced, while peak exercise capacity, heart rate and systolic blood pressure also showed improvements. Exercise capacity and quality of life were also shown to increase following 8 weeks of physical training in separate group of Syndrome X patients (28).
Aerobic exercise has been repeatedly shown to have positive effects on psychological wellbeing, anxiety and depression (29). Patients suffering clinical levels of anxiety and depression have shown a reduction in the severity of their symptoms(30)while athletes and the very active became depressed when they were prevented from exercising(31). Studies involving exercise, anxiety and wellbeing the older population are limited, however subjective health and psychological wellbeing have been shown to be higher among older people who partake in regular exercise (32). Anxiety reduction and increased wellbeing has also been shown in elderly men following an 8-week weekly exercise intervention (33).
Therefore, we would like to explore the beneficial effects of cardiac rehabilitation in Syndrome X patients. Exercise is not currently recognised as a treatment regime for Syndrome X, either as a stand- alone intervention or in conjunction with any other therapy. Patients are currently given little advice or guidance relating to physical activity due to the lack of research and information regarding the potential benefit of exercise available to practitioners. Our previous investigations of Syndrome X have demonstrated a need for an intervention which would not only reduce the patients reported levels of anxiety, but also increase their perceived social support, psychological wellbeing and quality of life. CR has been shown to improve quality of life, reduce anxiety and decrease frequency of angina episodes in CHD patients through the use of exercise intervention and tangible social support. Therefore, we would like to investigate the following research questions:
Does cardiac rehabilitation:
1. Reduce the frequency and severity of angina attacks in Syndrome X?
2. Reduce anxiety, depression and health related worry found in Syndrome X?
3. Improve the quality of life of Syndrome X patients?
1. Kemp HG, Jr., Vokonas PS, Cohn PF, Gorlin R. The anginal syndrome associated with normal coronary arteriograms. Report of a six year experience. Am J Med 1973; 54(6):735-742.
2. Cannon RO, III, Epstein SE. "Microvascular angina" as a cause of chest pain with angiographically normal coronary arteries. Am J Cardiol 1988; 61(15):1338-1343.
3. Raymond C. Chest pain not always what it seems; panic disorder may be cause in some. JAMA 1989; 261(8):1101-1102.
4. Sax FL, Cannon RO, III, Hanson C, Epstein SE. Impaired forearm vasodilator reserve in patients with microvascular angina. Evidence of a generalized disorder of vascular function? N Engl J Med 1987; 317(22):1366-1370.
5. Cannon RO, III, Bonow RO, Bacharach SL, Green MV, Rosing DR, Leon MB et al. Left ventricular dysfunction in patients with angina pectoris, normal epicardial coronary arteries, and abnormal vasodilator reserve. Circulation 1985; 71(2):218-226.
6. Opherk D, Schuler G, Wetterauer K, Manthey J, Schwarz F, Kubler W. Four-year follow-up study in patients with angina pectoris and normal coronary arteriograms ("syndrome X"). Circulation 1989; 80(6):1610-1616.
7. Shapiro LM, Crake T, Poole-Wilson PA. Is altered cardiac sensation responsible for chest pain in patients with normal coronary arteries? Clinical observation during cardiac catheterisation. Br Med J (Clin Res Ed) 1988; 296(6616):170-171.
8. Dean JD, Jones CJ, Hutchison SJ, Peters JR, Henderson AH. Hyperinsulinaemia and microvascular angina ("syndrome X"). Lancet 1991; 337(8739):456-457.
9. Potts SG, Bass CM. Psychological morbidity in patients with chest pain and normal or near- normal coronary arteries: a long-term follow-up study . Psychol Med 1995; 25(2):339-347.
10. Ruggeri A, Taruschio G, Loricchio ML, Samory G, Borghi A, Bugiardini R. [The correlation between the clinical characteristics and psychological status in syndrome X patients]. Cardiologia 1996; 41(6):551-557.
11. Mayou R. Chest pain, palpitations and panic. J Psychosom Res 1998; 44(1):53-70.
12. Cunningham C, Brown S, Kaski JC. Effects of transcendental meditation on symptoms and electrocardiographic changes in patients with cardiac syndrome X. Am J Cardiol 2000; 85(5):653-5, A10.
13. Ornish D, Scherwitz LW, Doody RS, Kesten D, McLanahan SM, Brown SE et al. Effects of stress management training and dietary changes in treating ischemic heart disease. JAMA 1983; 249(1):54-59.
14. Luebbert K, Dahme B, Hasenbring M. The effectiveness of relaxation training in reducing treatment-related symptoms and improving emotional adjustment in acute non-surgical cancer treatment: a meta-analytical review. Psychooncology 2001; 10(6):490-502.
15. Atienza F, Velasco JA, Brown S, Ridocci F, Kaski JC. Assessment of quality of life in patients with chest pain and normal coronary arteriogram (syndrome X) using a specific questionnaire. Clin Cardiol 1999; 22(4):283-290.
16. Sand NP, Juelsgaard P. [Syndrome X. Somatic and social prognosis of patients with angina pectoris and normal coronary arteriography]. Ugeskr Laeger 1994; 156(8):1131-1136.
17. Asbury EA, Creed F, Collins P. Distinct psychosocial differences between women with coronary heart disease and cardiac syndrome X. Eur Heart J 2004; 25 (19):1695-1701.
18. Grace SL, Abbey SE, Shnek ZM, Irvine J, Franche RL, Stewart DE. Cardiac rehabilitation I. review of psychosocial factors. Gen Hosp Psychiatry 2002; 24(3):121-126.
19. Yoshida T, Kohzuki M, Yoshida K, Hiwatari M, Kamimoto M, Yamamoto C et al. Physical and psychological improvements after phase II cardiac rehabilitation in patients with myocardial infarction. Nurs Health Sci 1999; 1(3):163-170.
20. Johnston M, Foulkes J, Johnston DW, Pollard B, Gudmundsdottir H. Impact on patients and partners of inpatient and extended cardiac counseling and rehabilitation: a controlled trial. Psychosom Med 1999; 61(2):225-233.
21. O'Callaghan WG, Teo KK, O'Riordan J, Webb H, Dolphin T, Horgan JH. Comparative response of male and female patients with coronary artery disease to exercise rehabilitation. Eur Heart J 1984; 5(8):649-651.
22. Woloshin S, Schwartz LM, Tosteson AN, Chang CH, Wright B, Plohman J et al. Perceived adequacy of tangible social support and health outcomes in patients with coronary artery disease. J Gen Intern Med 1997; 12(10):613-618.
23. Horsten M, Mittleman MA, Wamala SP, Schenck-Gustafsson K, Orth-Gomer K. Depressive symptoms and lack of social integration in relation to prognosis of CHD in middle-aged women. The Stockholm Female Coronary Risk Study. Eur Heart J 2000; 21(13):1072-1080.
24. Wenger NK. Social support and coronary heart disease in women: the challenge to learn more. Eur Heart J 1998; 19(11):1603-1605.
25. Lindsay GM, Smith LN, Hanlon P, Wheatley DJ. The influence of general health status and social support on symptomatic outcome following coronary artery bypass grafting. Heart 2001; 85(1):80-86.
26. Anderson D, Deshaies G, Jobin J. Social support, social networks and coronary artery disease rehabilitation: a review. Can J Cardiol 1996; 12(8):739-744.
27. Eriksson BE, Tyni-Lenne R, Svedenhag J, Hallin R, Jensen-Urstad K, Jensen-Urstad M et al. Physical training in Syndrome X: physical training counteracts deconditioning and pain in Syndrome X. J Am Coll Cardiol 2000; 36(5):1619-1625.
28. Tyni-Lenne R, Stryjan S, Eriksson B, Berglund M, Sylven C. Beneficial therapeutic effects of physical training and relaxation therapy in women with coronary syndrome X. Physiother Res Int 2002; 7(1):35-43.
29. Salmon P. Effects of physical exercise on anxiety, depression, and sensitivity to stress: a unifying theory. Clin Psychol Rev 2001; 21(1):33-61.
30. Craft LL, Landers D.M. The effect of exercise on clinical depression and depression resulting from mental illness: A meta analysis. Journal of Sport and Exercise Psychology 20, 339-357. 1998.
31. Aidman EV, Woollard S. The influence of self-reported exercise addiction on acute emotional and physiological responses to brief exercise deprivation. Psychology of Sport and Exercise. 2002.
32. Ransford HE, Palisi BJ. Aerobic exercise, subjective health and psychological well-being within age and gender subgroups. Soc Sci Med 1996; 42(11):1555-1559.
33. Perrig-Chiello P, Perrig WJ, Ehrsam R, Staehelin HB, Krings F. The effects of resistance training on well-being and memory in elderly volunteers. Age Ageing 1998; 27(4):469-475.
Allocation: Randomized, Control: Active Control, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Phase III group based cardiac rehabilitation
National Heart and Lung Institute, Imperial College London
National Heart and Lung Institute
Published on BioPortfolio: 2014-08-27T03:52:49-0400
The purpose of this study is to determine whether cardiac rehabilitation is a successful treatment for refractory angina, in relation to improvements in cardiovascular risk factors, physic...
The purpose of this study is to determine the effectiveness of Ranolazine for the treatment chest pain from disease of small vessels of the heart also known as 'microvascular angina'.
Angina is the most common symptom of coronary heart disease among women but unlike men most women do not have stenosis of the coronary arteries. In a large proportion of these women, coron...
The Primary Objective of this study: -To assess the effects of SAR407899 on coronary vasomotor function using the coronary flow reserve (CFR) in patients with microvascular angina and/or ...
The purpose of this study is to determine if long-term vasodilatory treatment is more effective than the standard treatment in hypertensive patients with microvascular angina pectoris
Non-obstructive coronary artery disease (NOCAD) on coronary angiography is a common finding in patients with stable angina. Angina in NOCAD patients is thought to be caused by endothelial dysfunction ...
Inpatient cardiac rehabilitation (ICR) programs provide important services to hospitalized patients by delivering risk factor education, daily ambulation, and facilitation of referral to outpatient ca...
: Cardiac rehabilitation is able to reduce cardiovascular mortality, and improves functional capacity and quality of life. However, cardiac rehabilitation participation rates are low and the current e...
A pilot study was conducted to determine if a smartphone-based adjunct to standard care could increase the completion rate of a cardiac rehabilitation program (CRP). Based on historical completion rat...
To assess the cost-effectiveness of 3 models of exercise-based cardiac rehabilitation (CR) compared with standard care in survivors of acute coronary syndrome (ACS) within the public health system in ...
ANGINA PECTORIS or angina-like chest pain with a normal coronary arteriogram and positive EXERCISE TEST. The cause of the syndrome is unknown. While its recognition is of clinical importance, its prognosis is excellent. (Braunwald, Heart Disease, 4th ed, p1346; Jablonski Dictionary of Syndromes & Eponymic Diseases, 2d ed). It is different from METABOLIC SYNDROME X, a syndrome characterized by INSULIN RESISTANCE and HYPERINSULINEMIA, that has increased risk for cardiovascular disease.
Restoration of functions to the maximum degree possible in a person or persons suffering from a CARDIOVASCULAR DISEASE. It also includes cardiac conditioning and SECONDARY PREVENTION in patients with elevated cardiovascular risk profile.
The period from onset of one menstrual bleeding (MENSTRUATION) to the next in an ovulating woman or female primate. The menstrual cycle is regulated by endocrine interactions of the HYPOTHALAMUS; the PITUITARY GLAND; the ovaries; and the genital tract. The menstrual cycle is divided by OVULATION into two phases. Based on the endocrine status of the OVARY, there is a FOLLICULAR PHASE and a LUTEAL PHASE. Based on the response in the ENDOMETRIUM, the menstrual cycle is divided into a proliferative and a secretory phase.
An adrenergic-beta-2 antagonist that has been used for cardiac arrhythmia, angina pectoris, hypertension, glaucoma, and as an antithrombotic.
The interval between two successive CELL DIVISIONS during which the CHROMOSOMES are not individually distinguishable. It is composed of the G phases (G1 PHASE; G0 PHASE; G2 PHASE) and S PHASE (when DNA replication occurs).
In a clinical trial or interventional study, participants receive specific interventions according to the research plan or protocol created by the investigators. These interventions may be medical products, such as drugs or devices; procedures; or change...
Cardiology is a specialty of internal medicine. Cardiac electrophysiology : Study of the electrical properties and conduction diseases of the heart. Echocardiography : The use of ultrasound to study the mechanical function/physics of the h...
Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”. Some illnesses can be excruci...