European Journal of Experimental Biology Open Access

Keywords

Anxiety; Fear; CABG; Coronary artery bypass grafting

Introduction

Undergoing cardiac operations, especially invasive procedures such as coronary artery bypass graft surgery (CABG) is a daunting prospect and is deemed an important life-event, partly due to the psycho-emotional impacts they exert on patients and their families [20]. Indeed, CABG may be a relatively common procedure with proven relief of signs and symptoms of angina and well-documented low mortality rates, but fear and anxiety are to be expected amongst patients scheduled for this surgical modality [6]. Different severity levels of anxiety have been reported for 20 to 55% of coronary artery disease patients [11] and the same prevalence ratios have been observed for patients candidate for CABG [18]. Anxiety can adversely affect surgical patients’ current well-being as well as their Intensive Care Unit and recovery periods [15,6,17,8]. What is more, throughout the operative course, not only does anxiety persist but it also intensifies. Mood disturbances and stress disorders can both influence the outcome of cardiac procedures via affecting physiological conditions such as increase of blood pressure, arterial damage, irregular heart rhythms, platelet reactivity, decreased heart variability and increased pro-inflammatory markers and intensify pain, worsen fatigue and sluggishness, and cause a person to withdraw into social isolation [1,13,16] .Anxiety has been reported more frequently in women than in men [7,2,3]. Appearance of these disorders around the time of surgery can predict postoperative complications and poor quality of life as well as occurrence of lifethreatening cardiac events and even higher rates of mortality [4]. For all the studies conducted hitherto on anxiety, there is a dearth of data in the existing literature on the variety of fear of and misconceptions about CABG amongst those candidates for this procedure [8,9,10]. A better understanding of fear is vitally important for decision-making about the appropriate and timely intervention and provision of information aimed at reducing patients’ uncertainties [9]. The present study primarily sought to identify the prevalence of fear and anxiety and then determine the variety and degrees of fear amongst CABG candidates.

Materials and Methods

Tehran Heart Center is a referral center where around 2500 heart surgical operation are performed annually. CABG accounts for the majority of these operations. The present study, approved by the Ethics Committee of Tehran Heart Center, initially recruited 295 patients hospitalized for CABG between October 2011 and January 2012. Patients were excluded if they did not have an acceptable command of the Persian language and were not thus able to complete the questionnaire (n=7), if they were in poor physical condition at the CCU or ICU (n=4), if they were reluctant to participate (n=4), and if they were scheduled to undergo emergency surgery (n=3). After the exclusion of these18 patients, the final sample consisted of 277 CABG candidates. Fear, anxiety, and demographic data questionnaires were given to the patients the day after hospitalization. The questionnaires were answered on a selfreported basis, unless the patient was illiterate, in which case assistance was provided by a research fellow. The fear questionnaire was designed according to the Bypass Grafting Fear Scale (BGFS) [14]. The language was adjusted by translation into Persian and then back translation into the original language, and the validity was thereafter reviewed and approved by some expert clinical researchers. The internal consistency of the questionnaire was measured via the Cronbach alpha in the first 30 patients, which yielded a result of 0.88. The result being significant, the study was continued with a larger population. This questionnaire comprised twelve questions, scored from 1 (without any fear) to 10 (high fear): Score1, no fear; Score 2-4, low fear; Score 5-7, moderate fear; and Score 8-10, high fear levels. Consequently, the intensity of fear was evaluated as mild for a total score of 24-48, moderate for 49-84, and severe for 85-144. The Spielberg Anxiety Questionnaire Inventory has two parts: trait and state. The Anxiety Inventory (STAI) assesses situational anxiety (state anxiety, STATE) and individual tendency to experience anxiety part, which is anxiety proneness (trait anxiety, TRAIT). In the present study, the state part, consisting of twenty items, was employed. The validity and reliability of this questionnaire had been previously proven in Iran [10]. The Spielberg Anxiety Questionnaire scoring ranges from 20 to 80 in the state part; and the higher the score, the greater the intensity of anxiety: mild, 20-31; moderate up to low, 32-42; moderate up to high, 43-53; almost severe, 54-64; severe, 65-75; and highly severe, over 75. The One-way ANOVA, t-test, and logistic regression analysis were utilized to measure the association of fear and anxiety with the other variables. Descriptive statistics were drawn upon to examine the intensity of fear and anxiety and the demographic data. The demographic data consisted of age, sex, marital status, education, history of psychiatric disorder, psychiatric medicine intake, cigarette smoking, and opium addiction.

Results

A total of 277 patients comprised our final sample, consisting of 183 (66.06%) male and 94 (33.93%) female patients. The sociodemographic characteristics are depicted in Table 1. Our results showed that 3.32% of our respondents reported no fear, 53.14% had low, 38.75% moderate, and only 4.80% high fear levels. Furthermore, 69.14% of our study population had moderate, 19.70% low, and11.15% severe anxiety levels (Table 2). Our results demonstrated that amongst our CABG candidates, fear of pain after surgery had the highest frequency, followed by fear of health deterioration, fear of myocardial infarction. Fear of recovery from operation and fear of uncertainly about illness had the lowest frequency (Table). There was a significant correlation between anxiety and fear (r=0.491). According to the Pearson results, no significant correlation was found between age and the intensity of fear or anxiety (r=-0.098, -0.060). The history of previous psychiatric disorders increased the intensity of anxiety significantly (p value <0. 01), whereas there was no significant correlation between fear and history of previous psychiatric disorders (p value >0.05); and nor was there any significant correlation between marital status (p value >0.05) and education (p value >0.05) and fear or anxiety. Current and past psychiatric medication intakes were found to have a significant correlation with the intensity of fear and anxiety (p value <0.05). The patients with a history of opium consumption had a significantly lower intensity of fear and anxiety (p value <0.05). History of cigarette smoking significantly decreased fear of CABG (p value <0.05); however, no such correlation existed with respect to anxiety in this subset of patients (p value >0.05).

Table 1. Demographic characteristics of the participants (n = 277)

Table 2. Level of fear and anxiety in the patients awaiting CABG

Table 3. The intensity of fear in the CABG candidates

Discussion

Every year a great number of cardiac operations are performed the world over, including Iran. Tehran Heart Center is a major referral hospital where approximately 2500 cardiac operations are carried out per annum. The average age of these patients is over 45 years, which is supposed to be the productive age. Hospitalization is a stressful experience and surgery, not least cardiac surgery, creates preoperative stress and anxiety. Fear and anxiety are the most common disorders amongst CABG candidates and as such interfere with the scheduling and recovering period of these patients [8,10]. Most patients tend to harbor such strong concerns about surgery that they cannot even share them with their physicians, which indubitably compromises the quality of medical care. Misleading or insufficient information, misconceptions, and a previous history of anxiety can beget fear and anxiety in patients scheduled for surgery and can thus reduce the outcome of the surgery and quality of life in the postoperative period. Prolonged hospitalization, intensified postoperative pain, and increased mortality and morbidity rates are some of the consequences of these psychological disorders [4,12]. Some of the most notable fear and anxiety causative factors are the patient’s false beliefs regarding the operation and postoperative symptoms. Intense fear and anxiety may be important predictors of coronary heart disease future outcomes [5] which render the identification of patients with high levels of fear and anxiety imperative [10]. A good insight into fears that a patient is liable to experience can help the treating physician furnish more effective education aimed at lessening such undesirable factors and this can expedite the postoperative recovery period [9].

In the current study, the principal fears of the patients were postoperative pain, fear of health deterioration, fear of recurrent myocardial infarction, and fear of recovery from operation in descending order. This finding does not chime in with a previous study, which reported fear of health deterioration as the chief concern, followed by recurrent myocardial infarction and pain and fear of being away from relatives [16]. It seems that aside from minimal differences, the assumptions and beliefs of the two study populations from two different countries are for all intents and purposes similar. It is deserving of note, however, that the factors that alleviate fear in patients are dissimilar. Dependency on the staff’s care and anesthesia were the least significant factors in the Finnish population. To be precise, fear of dependency on the staff’s care and anesthesia amongst Iranian patients was found to be moderate and higher than the level reported in the Finnish population [10]. Furthermore, ten percent of our population self-reported high levels of fear, and this does not appear consistent with the results of the aforementioned study; patients’ different cultural and educational backgrounds and different information sources can explain these dissimilarities. As a result, devising an educational program to ease fear and anxiety in these two different populations would necessitate that suckh differences be taken into consideration. The average scores of fear and anxiety in these two populations were almost equal, and women and patients with a history of psychiatric disorders were more vulnerable. In our study, there was no significant correlation between fear and anxiety and vocational educations, marital status, and disease duration; whereas in previous studies, the correlation between these variables and fear and anxiety was significant [8,10]. In most of these studies, woman had higher intensity of fear and anxiety [7,2,3,10]. This finding was borne out by our results as well.

Conclusion

CABG has become a relatively common surgical operation in the recent decade. Be that as it may, most of the patients scheduled to undergo this surgical modality are likely to experience moderate or high fear levels, more often than not in consequence of misinformation and misconceptions. This requires timely medical interactions and wellthought- out educational programs to enhance treatment outcomes and quality of life. Needless to say, further studies are required to probe into individual life situations and fears of cardiac surgery candidates if more effective educational programs are to be devised.

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