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Psychosomatic Medicine 61:488-495 (1999)
© 1999 American Psychosomatic Society

ORIGINAL ARTICLES

Cognitive Adaptation as a Predictor of New Coronary Events After Percutaneous Transluminal Coronary Angioplasty

Vicki S. Helgeson, PhD and Heidi L. Fritz, PhD

From Carnegie Mellon University (V.S.H.) and University of Pittsburgh (H.L.F.), Pittsburgh, PA.

Address reprint requests to: Vicki S. Helgeson, PhD, Psychology Department, Carnegie Mellon University, Pittsburgh, PA 15213. Email: vh2e+{at}andrew.cmu.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: We tested whether the psychological components of cognitive adaptation theory would predict new coronary events after a first percutaneous transluminal coronary angioplasty (PTCA).

METHODS: A consecutive sample of patients treated successfully with PTCA were enrolled in the study. Of 343 patients approached, 303 (88%) agreed to participate and were interviewed shortly before hospital discharge. We measured the components of cognitive adaptation theory (optimism, self-esteem, and mastery) during the interview. Five patients were excluded from the analysis because of early, in-hospital reocclusion. New cardiac events (coronary artery bypass grafting, PTCA, myocardial infarction, or disease progression) were examined within 6 months of the first PTCA. We obtained 6-month follow-up data on 98% of patients.

RESULTS: The cognitive adaptation index predicted new cardiac events, even when demographic variables and medical variables thought to predict restenosis were statistically controlled (p = .02).

CONCLUSIONS: These results suggest that persons who respond to their illness by perceiving control over their futures, by having positive expectations about their futures, and by holding a positive view of themselves seem to be at less risk for a new cardiac event after a first PTCA.

Key Words: angioplasty • new cardiac events • restenosis • psychological variables

Abbreviations: CABG = coronary artery bypass grafting; CI = confidenceinterval; LAD = left anterior descending (artery); MI =myocardial infarction; PTCA = percutaneous transluminal coronaryangioplasty.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
PTCA, or angioplasty, is a procedure that has been used for nearly two decades to treat coronary artery disease. In 1995, more than 400,000 PTCA procedures were performed in the United States (1). The frequency with which PTCA is used has grown rapidly, in part because of its less invasive nature compared with CABG. The initial success rate of angioplasty is high (90–95%), meaning that it is nearly always effective in opening the artery and reducing a blockage to at least below 50% (2, 3). However, the major difficulty with PTCA is restenosis. Between 30% and 40% of blockages reocclude, most during the first 6 months after the procedure (4, 5). The rate of restenosis for traditional balloon angioplasty has not changed over the past two decades. New coronary events also are not uncommon in the first year after angioplasty.

A number of physiological variables may predict new coronary events. To the extent that new coronary events are a result of restenosis, a number of risk factors have been identified. The particular artery that is dilated predicts restenosis, with the LAD artery having a higher restenosis rate than other arteries (6). The severity of the initial blockage and the extent to which the artery is initially dilated also have been shown to predict restenosis (6, 7). These variables are likely to predict new coronary events.

Studies of angioplasty patients, however, have rarely examined the extent to which psychological variables might affect new coronary events or restenosis. Only one study, to our knowledge, has examined whether psychological factors predict restenosis. Goodman et al. (8) found that hostility predicted restenosis among a small group of patients (N = 41) treated with traditional balloon angioplasty. These investigators defined restenosis on the basis of repeated cardiac catheterization. However, this procedure was performed only on patients who evidenced complaints of symptoms. The investigators acknowledge that silent restenosis would not have been detected. Another study focused on the prediction of new coronary events over an 18-month period among patients who were successfully treated for coronary artery disease with angioplasty (9). These investigators found that anger and vital exhaustion (defined as lack of energy, demoralization, and increased irritability) predicted new coronary events when risk factors of heart disease and residual stenosis after PTCA were statistically controlled.

A set of positive psychological variables, captured under the title "cognitive adaptation theory" (10, 11), have been shown in various forms to predict psychological adjustment to diseases such as arthritis (12), cancer (10, 13), AIDS (14), and heart disease (15). According to cognitive adaptation theory, people successfully adjust to chronic illness by engaging in a series of mildly positive self-relevant distortions. Faced with a chronic illness, some individuals maintain or develop an optimistic outlook, attempt to regain control or mastery over the event, and find ways to restore or enhance their self-esteem. We measured markers of cognitive adaptation theory and tested whether people with these characteristics would be less vulnerable to a new coronary event within 6 months of the initial angioplasty. The majority of these coronary events are likely to be the result of restenosis.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Patients
Patients were eligible to participate in the study if they were 80 years of age or younger, admitted for coronary artery disease (eg, MI or unstable angina), had never been treated surgically for coronary artery disease (ie, no history of PTCA or CABG), and were successfully treated with PTCA. Patients were excluded if they currently had another life-threatening disorder (eg, terminal cancer or end-stage renal disease), some other form of heart disease (eg, valvular disease or cardiomyopathy), or a history of psychiatric hospitalization for thought disorder (eg, schizophrenia).

Successful PTCA was defined as 20% or greater reduction in the diameter of stenosis and a residual diameter stenosis below 50%, without complications such as MI, CABG, or death (2, 5). We also considered PTCA to be successful only if the blockage did not reocclude while the patient was still in the hospital.

We approached 343 patients who met the above criteria and were consecutively admitted to the hospital between December 1993 and October 1996. Of these, 303 (88%) agreed to participate in the study and signed an informed consent form. Patients were approached 1 or 2 days after PTCA. Interviews lasted 45 to 60 minutes. Among the 303 patients, five had blockages that reoccluded after they were interviewed but before they were discharged from the hospital. Thus, these patients’ data were excluded from the study (inclusion of these five patients, however, did not alter the results). Our final sample consisted of 298 patients (199 male and 99 female). The admission diagnosis for patients was coronary artery disease (9%), unstable angina or chest pain (30%), acute or rule out MI (38%), or positive treadmill test (22%).

Six months later, we were able to reach 292 of the 298 patients (98%) and their physicians to determine whether patients had been rehospitalized for an additional coronary event. We verified all rehospitalizations with medical records.

Data Collection
We obtained demographic information (eg, age and education) from patient interviews. We reviewed medical records for coronary risk factors (eg, history of smoking and history of hypertension), information related to disease severity (eg, number of diseased vessels), and information related to the angioplasty (eg, kind of procedure used). This information is provided in Table 1. The majority of patients had only a single vessel dilated but some (N = 39, 13%) had a second vessel dilated. For patients who had PTCA in two arteries, we used the artery with the most severe blockage to calculate the percentage of stenosis before and after PTCA. Because the LAD is the most likely artery to reocclude, for data analytic purposes, we classified patients according to whether the LAD was dilated. For the kind of angioplasty procedure used, we grouped traditional balloon angioplasty with atherectomy and compared both groups to patients who had a coronary stent. (Placing the 19 patients who had atherectomies into the stent category did not alter the results.) Restenosis after use of coronary stents is typically lower than that for traditional balloon angioplasty (16, 17).


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  		Table 1. Characteristics of the Sample
 

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  		Table 1A. —Continued
 
Cognitive Distortions.
The three components of cognitive adaptation theory were measured: self-esteem, optimism, and control. We used two indicators of each variable, one that reflects a general personality trait and one that reflects a response to the specific situation (ie, adjustment to heart disease). The eight-item Life Orientation Test (LOT) was used to measure dispositional optimism (18, 19). We created a six-item situation-specific version of the LOT to measure optimism about recovery from heart disease (eg, I have a positive attitude about my recovering from this heart problem). Dispositional self-esteem was measured with the 10-item Rosenberg (20) global self-esteem scale. A two-item denial of illness impact scale (ie, admitting one is ill but minimizing the severity of the problem) was used to measure self-esteem (21). A sample item is "It takes more than a heart problem to make me fall apart." We administered Pearlin and Schooler’s (22) seven-item mastery scale to measure general feelings of personal control. The items in all of these instruments were rated on a five-point rating scale (1 = strongly disagree and 5 = strongly agree). Finally, we asked patients to identify three ways that they could control their heart disease and then to indicate the extent to which they were able to exert these forms of control (eg, "To what extent are you able to quit smoking?") on five-point scales (1 = not at all and 5 = completely). These latter questions reflected the situation-specific measure of control or self-efficacy.

All but one pair of these variables were significantly positively intercorrelated. Correlation coefficients ranged from 0.12 to 0.50, with an average of 0.32. Principal components analysis of the six variables revealed that they all loaded on a single factor. Thus, we created a single cognitive adaptation index by standardizing each of the above variables and then summing them. Composite indices are generally more reliable than single scales. The cognitive adaptation index reflects high self-esteem, high perceived control, and high optimism, in general and with respect to the illness. The internal consistency of the index was good ({alpha} = 0.76).

Other Psychological Variables.
During the in-hospital interview, we measured psychological distress and perceived availability of support. We used the subscales from the Brief Symptom Inventory (23) to measure depression (six items; {alpha} = 0.86), anxiety (six items; {alpha} = 0.80), hostility (five items; {alpha} = 0.75), and somatization (ie, symptoms; seven items; {alpha} = 0.74). Items were rated on five-point scales (1 = never and 5 = very often). We used 11 items from the UCLA Social Support Inventory (24) to measure perceived availability of support from spouse, family and friends, and physician ({alpha} = 0.89).

We measured health behavior during the initial hospitalization and at 6 months of follow-up. Health behavior was a composite index of self-reports of regular exercise (none; some but irregular; or regular, defined as three times per week for 30 minutes each); smoking (current smoking status); adherence to a low-fat, low-cholesterol diet; time for relaxation; and perceived stressfulness of lifestyle (the latter three items were rated on five-point scales). The internal consistency of this index was somewhat low during hospitalization ({alpha} = 0.55) and at follow-up ({alpha} = 0.48), which is to be expected because health behaviors are often uncorrelated.

New Cardiac Events.
Patients were considered to have had a new coronary event if any of the following occurred within 6 months of hospital discharge: death from coronary artery disease, CABG, PTCA, MI, and/or progression of disease. We obtained this information from patients’ reports and from cardiac testing performed by the patient’s physician (eg, stress tests and cardiac catheterization reports). We verified patients’ reports of events with physician records.

We defined progression of disease as the appearance of a new blockage of more than 50% or restenosis of the originally angioplastied blockage. We defined restenosis as loss of 50% or more of the initial diameter gain and residual stenosis of more than 50%. Progression of disease was documented by cardiac catheterization. Cardiac catheterization, in and of itself, was not defined as a new coronary event. Of the 72 patients who had catheterizations within 6 months of discharge, 18 (25%) had vessels that remained patent, 48 (67%) had vessels that reoccluded, and six (8%) had occlusion of a new vessel without reocclusion of the originally dilated vessel.

Within 6 months, 57 of the 292 patients had sustained a new coronary event (20%). Some patients, however, had multiple events. Fifteen (15) patients had CABG, 44 patients had another PTCA (four of those went on to have CABG), two patients had an MI (both went on to have PTCA), and 55 patients had progression of disease (only two of these patients did not have CABG or PTCA). Thus, only two of the 57 patients defined as having a new coronary event had only catheter-documented disease progression without medical intervention (ie, PTCA or CABG).

Data Analysis
First, we used {chi}2 analysis and independent t tests to determine whether demographic variables, coronary risk factors, and medical variables thought to predict restenosis were associated with the incidence of a new coronary event. To be conservative, we statistically controlled for any of these variables that showed relations to new coronary events at p < .10 (two-tailed test). The variables examined are shown in Table 1. Then, we used logistic regression analysis to test whether the cognitive adaptation index predicted a new coronary event, when significant demographic and medical variables were statistically controlled. We used a significance level of p < .05 (two-tailed test) as our criterion for statistical significance. Finally, we examined whether hostility, anxiety, depression, somatization, social support, and health behavior would explain any observed relation between the cognitive adaptation index and new coronary events.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Demographic and Medical Variables
None of the demographic variables predicted new coronary events. In particular, neither education nor occupational status were associated with new coronary events (r = -0.04, not significant; r = 0.06, not significant, respectively). There was a weak trend for younger patients to be more likely than older patients to sustain a new event (t(290) = 1.81, p = .07). Thus, age was statistically controlled in all analyses. Gender was not related to age and did not predict new events. The latter finding is consistent with previous research showing that men and women have similar long-term outcomes after PTCA (25). None of the coronary risk factors or disease severity variables predicted a subsequent event. Even when coronary risk factors were measured as continuous variables (high cholesterol as the level of low-density and high-density lipoprotein; hypertension as admission systolic blood pressure; diabetes as blood glucose levels; and smoking as packs per day), none predicted new coronary events. Among the medical variables thought to predict restenosis, severity of occlusion after the angioplasty (t(df = 290) = -3.23, p < .001), occlusion of the LAD artery ({chi}2(df = 1) = 3.14, p = .08), and the angioplasty procedure used ({chi}2(df = 1) = 5.64, p < .05) predicted subsequent events. All of these relations were in the expected directions. Thus, we statistically controlled for these variables in subsequent analyses. To be conservative, we also controlled for two variables that did not significantly predict subsequent events but could obscure important relations: severity of occlusion before angioplasty and number of arteries occluded more than 50%.

We also examined the classes of medication patients were given on hospital discharge. Specifically, we examined angiotensin-converting enzyme inhibitors; ß blockers; calcium channel blockers; and antihypertensive, antiplatelet, nitrate, antiarrhythmic, diuretic, anticholesterol, and anticoagulant agents. We also examined antidepressants and antianxiety medications, although only 4% of patients were prescribed these. Among the classes of medications, nitrates were significantly associated with a reduced incidence of new coronary events ({chi}2(df = 1) = 4.62, p < .05), and anticholesterol medications were marginally associated with a reduced incidence of new coronary events ({chi}2(df = 1) = 3.39, p = .07). Thus, we controlled for both of these classes of medications in the analyses.

Cognitive Adaptation Index
The cognitive adaptation index was not related to indicators of disease severity or medical variables related to the angioplasty. Among the demographic variables, the cognitive adaptation index was related only to age (r = 0.17, p < .01), such that older people had higher scores on cognitive adaptation than younger people. Among the classes of medications, the cognitive adaptations index was correlated with a lower likelihood of being prescribed antianxiety medications (r = -0.22, p < .001) and antidepressants (r = -0.15, p < .01) and a greater likelihood of being prescribed ß-blockers (r = 0.14, p < .05). Recall that none of these medication classes were associated with new coronary events.

Logistic regression analysis showed that the cognitive adaptation index alone predicted new events (ß = -0.54, p = .01). The odds ratio was 0.58 (CI = 0.38–0.88). After adjusting for age, number of diseased vessels, percentage of stenosis before PTCA, percentage of stenosis after PTCA, dilation of the LAD, kind of angioplasty procedure used, and the two discharge medication classes (nitrates, anticholesterol agents), we tested whether the cognitive adaptation index would continue to predict subsequent events. The cognitive adaptation index remained a significant predictor of new coronary events. These results are shown in Table 2. The odds ratio for the cognitive adaptation index was 0.59 (CI = 0.38–0.93). Among the demographic and medical control variables in the final logistic regression equation, residual stenosis after PTCA, nitrates, and anticholesterol medications remained significant predictors of new cardiac events, and the LAD artery was a marginal predictor of new cardiac events. That is, higher residual stenosis after PTCA and dilation of the LAD artery were both associated with new cardiac events, whereas use of nitrates and use of anticholesterol medications were associated with a reduced incidence of new cardiac events.


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  		Table 2. Logistic Regression: Predicting New Coronary Events
 
We divided patients’ scores on the cognitive adaptation index into thirds. Figure 1 shows the percentages of patients in three groups who had a new coronary event. Patients who scored in the lower third of the index were three times as likely as patients who scored in the upper third of the index to sustain a new coronary event.



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  		Fig. 1. Percentage of patients who had a new coronary event within three groups: low, medium, and high in cognitive adaptation to heart disease.

 
We repeated the logistic regression analysis by testing which of the three components of the cognitive adaptation index accounted for the relation to new events. In this analysis, we entered the self-esteem index, the optimism index, and the control index on a stepwise basis, after controlling for demographic and medical variables. Each index was the sum of its two indicator variables. Although each index showed roughly equal relations to new coronary events, only the self-esteem index entered the equation (ß = -0.50, p < .05). The odds ratio was 0.61 (CI = 0.41–0.90). However, the significance of the optimism index was p = .07 before entry, making it a nearly equivalent predictor.

We also wondered whether the state variables (ie, reactions to the illness) would be better predictors than the trait variables (ie, dispositions) of new coronary events. We acknowledge, however, that measuring the trait variables after the onset of illness is likely to have made them more similar to the state variables. We would have had better markers of trait variables if we had measured them before the onset of illness. In this analysis, we entered the trait index (self-esteem, optimism, and mastery) and the state index (denial of illness impact, optimism about illness, and self-efficacy) on a stepwise basis, after controlling for the demographic and medical variables. The two indices showed roughly equal relations to new coronary events, but only the trait index entered the equation (ß = -0.38, p < .05). The odds ratio was 0.68 (CI = 0.48–0.98). It appears that the best predictor of new coronary events is the cognitive adaptation index as a whole rather than either of these combinations of its components.

Next we sought to determine whether other variables assessed during the initial interview could explain the relations of the cognitive adaptation index to new coronary events. The cognitive adaptation index was inversely associated with hostility (r = -0.28, p < .001), anxiety (r = -0.41, p < .001), depression (r = -0.41, p < .001), and somatization (r = -0.23, p < .001) and was positively associated with perceived availability of support (r = 0.35, p < .001). The cognitive adaptation index was associated with good health behavior at baseline (r = 0.25, p < .001) and at follow-up (r = 0.21, p < .001) and was marginally associated with improvements in health behavior between baseline and follow-up (r = 0.11, p = .09). Among these six variables, only hostility and anxiety revealed associations with new coronary events, but their relations were marginal (hostility: ß = 0.41, p = .10; odds ratio = 1.5, CI = 0.93–2.44; anxiety: ß = 0.37, p = .08; odds ratio = 1.45, CI = 0.96–2.21). When hostility was entered into the equation after the statistical control variables, the cognitive adaptation index remained significant (ß = -0.48, p = .04), but hostility was not significant (ß = 0.26, p = .36). When anxiety was entered into the equation after the statistical control variables, the cognitive adaptation index became a marginally significant predictor (ß = -0.44, p = .08), but anxiety was not significant (ß = 0.21, p = .38). Thus, the cognitive adaptation index was a stronger prediction of new coronary events than either hostility or anxiety. Unfortunately, it seems that none of these variables—anxiety, hostility, depression, somatization, social support, or health behavior—can explain the relation of the cognitive adaptation index to new coronary events.

One difficulty with this study is that we do not know the state of disease for patients who did not have subsequent cardiac testing or did not see their physician. Presumably, someone who saw the physician had the opportunity to report symptoms and the opportunity for the physician to obtain information about his or her health status, typically through stress testing. However, much less is known about patients who did not return to see their physician. Some of these people may have had disease progression without symptoms, and some may have had disease progression with symptoms but chose not to see a doctor. In this sample, 226 of the 292 patients (77%) saw their physician at least once during the 6-month period for a stress test. The cognitive adaptation index was not associated with visiting the physician (r = -0.01, p = .93). If we restrict our analysis to patients who saw their physician at least once over the 6 months, so that the opportunity to detect restenosis and disease progression was at least possible, the cognitive adaptation index continues to predict new cardiac events (ß = -0.54, p = .03; odds ratio = 0.58, CI = 0.36–0.94).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
Previous studies have shown that people successfully adjust to traumatic events, such as the onset of chronic illness, by establishing a sense of control over the event, restoring damaged self-esteem, and developing a positive outlook. This study demonstrates that people who respond to a first coronary event in these ways also may reduce their risk of a subsequent coronary event. PTCA is a treatment for coronary artery disease that has a high primary success rate but also a relatively high restenosis rate. Thus, these individuals are at risk for a subsequent coronary event over a relatively short time period. Because restenosis occurs rapidly, most often within 6 months, it has been assumed to largely reflect a physiological process. Indeed, numerous physiological predictors of restenosis have been identified. This is one of the few studies to show that one’s psychological state may affect the occurrence of new coronary events that are largely presumed to reflect restenosis. Events that occur within 6 months after PTCA are thought to reflect restenosis, whereas later events are more likely to reflect progression of disease among other coronary arteries (26–28). The cognitive adaptation index predicted new coronary events, even when physiological risk factors for restenosis were statistically controlled.

How could one’s psychological state, the way one cognitively adapts to coronary artery disease, influence physiology? Patients who scored high on the cognitive adaptation index reported greater support from family, friends, and their physician; less hostility, anxiety, depression, and somatization; and better health behavior before and after their hospitalization. Unfortunately, none of these variables explained the relation of the cognitive adaptation index to new events.

That health behavior changes do not account for the relation of the cognitive adaptation index to new coronary events is particularly surprising. However, it is possible that the important health behavior changes were not captured in this study. It would have been best to measure the changes made between hospital discharge and the onset of the new coronary event. Instead, we measured health behavior 6 months after hospitalization, which could reflect health behavior changes made in response to the original event or in response to the new coronary event. Our measure of health behavior also was rather crude. We relied on simple self-report measures of smoking cessation, exercise, and dietary changes. More elaborate self-report measures along with physiological measures may provide better indicators of health behavior change. A positive regard for the self, an optimistic outlook toward the future, and the belief that one can make necessary lifestyle changes may have altered patients’ behavior in other ways that influenced their disease course, ways that we did not adequately detect in this study.

It also is possible that the cognitive adaptation index influenced the incidence of new coronary events by altering people’s perceptions of stress or the actual occurrence of stressors. Stress has been shown to affect episodes of ischemia (29–31). People who score high on the cognitive adaptation index may be less physiologically reactive to stressors, may face fewer stressors in their lives, or may be less likely to interpret events as stressful because of their greater social and personal resources.

Alternatively, the psychological states of the cognitive adaptation index may have had direct effects on physiological processes that could lead to new coronary events. The precise physiological process that underlies restenosis is not certain (28). However, it is assumed that the primary physiological mechanism is a proliferative response of smooth muscle cells to arterial injury (28). The question is whether psychological factors could trigger this proliferative response.

Twenty percent (20%) of patients had a new event within 6 months of their angioplasty, the majority of which were likely due to restenosis. In fact, 50 of the 57 (88%) patients who had a new event were documented by catheterization to have restenosis of the originally dilated artery. The remaining patients had progression of disease in other arteries that was treated by an additional PTCA in six patients and CABG in one patient. Even when these seven patients were excluded from the analysis, the cognitive adaptation index continued to predict new coronary events. The percentage of new cardiac events detected in this study is consistent with data reported in previous studies (9, 16, 32).

One limitation of this study is that the extent of restenosis is not fully known for the entire sample of patients. This is a common difficulty with PTCA studies (eg, Ref. (8)). Undoubtedly, some patients had arteries that restenosed without evidence of symptoms, or silent restenosis. Thus, we are not predicting restenosis per se but new coronary events that are likely to be the result of restenosis. The only way to determine medical restenosis for the entire sample of patients would be to submit all patients to a second cardiac catheterization, which is not a benign or cost-free request. For this reason, we conservatively defined new coronary events as clinically documented disease progression. Only 73 patients had repeat catheterizations, but the majority of patients at least saw the physician (N = 226, 77%) and had a stress test (N = 213, 73%), which would have given the physician some indication of whether further testing was warranted. Recall that the cognitive adaptation index predicted new coronary events when the analysis was restricted to those patients who saw their physicians at least once over the 6 months.

On a related note, patients who had repeated catheterizations in this study may not be representative of the entire sample of patients. It is likely that these patients either experienced symptoms or had positive results on a stress test. Several studies have shown that emotional distress, particularly the personality trait of anxiety, predict the experience of symptoms (33–36). Symptoms are often uncorrelated, however, with disease progression (37). Moreover, anxiety is not predictive of disease progression. Patient-reported anxiety was actually associated with fewer coronary events over 5 years in one study (35), and our own study showed that anxiety did not predict new coronary events after controlling for demographic and medical risk factors.

Despite our inability to document the state of all patients’ coronary arteries or to determine the pathway through which the cognitive adaptation index influenced new cardiac events, the results of this study present a compelling case: Above and beyond the contributions of demographic and medical risk factors, patients’ cognitive approaches and responses to their illness may influence the onset of new coronary events that warrant medical attention.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
This study was supported by a FIRST Award (V.S.H.) from the National Institutes of Health (5R29 MH48662). We extend our appreciation to the physicians, staff, and patients of Shadyside Hospital for their support of this work. We are grateful to Dr. Krishna V. Tummalapalli, codirector of echocardiology at Shadyside Hospital, for his comments on a previous draft of this manuscript and his classification of patient discharge medications. We also thank Rocco Mercurio for interviewing the patients in this study and Tonya Karaczun for her assistance with preparation of this manuscript.

Received for publication October 12, 1998.

Revision received February 11, 1999.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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