The role of medical and psychosocial factors for unfavourable coronary risk factor control

Figures & data

Figure 1. Flow chart of the NOR-COR study.

Figure 2. The NOR-COR model.

Table I. Main data collections in the NOR-COR study.

Variables collected from the hospital record (participants and 96% of the non-participants)

Socio-demographic factors

Marital status (in a relationship/living alone)

Employment status^a

Ethnicity (1st and 2nd generation patients born in Asia, Africa and South America)

Medical factors

Coronary aetiology (acute myocardial infarction vs. stable coronary disease)

Number of coronary events (1 vs. >1)

Angiographic findings (open vessels, atherosclerosis without significant stenosis, single and multi-vessel disease)

Type of coronary intervention (no intervention, percutaneous coronary intervention, coronary artery bypass graft operation)

Participation in the cardiac rehabilitation programme

Time since the event (2–12 months and 12–36 months)

Coronary risk factors at discharge (blood pressure, cholesterol, diabetes)

Somatic co-morbidity calculated using the Charlson co-morbidity Index [27]

Psychiatric co-morbidity (anxiety, depression) and the use of psychotropic drugs at discharge

Medication at discharge (antiplatelets, beta-blockers, ACE/ARB, nitrates, diuretics, anxiolytics, antidepressant)

Type and dosage of lipid lowering drugs at discharge

Variables collected from the self-report questionnaire (participants only)

Socio-demographic factors

Level of education (high/low)^b

Medical factors

Smoking status (current, previous, never and package-year)

Physical activity (frequency, duration, intensity) [25]

Diet (the frequency or amount of intake of different types of foods, beverages and meals) [30]

Obstructive sleep apnea (Berlin questionnaire) [29]

Alcohol consumption (frequency, units/week) [31]

Name, dosage and side-effects of current antiplatelet and lipid lowering drugs

Drug adherence (The 8-item Morisky Medication Adherence Scale) [28]

Adherence with antiplatelet and lipid lowering drugs past week (7/7, 6/7, 5/7, ≤4/7)

Psychosocial factors

Anxiety and depression (Hospital Anxiety and Depression Scale) [22]

Rumination (Ruminative Response Scale) [18]^c

Worry (Penn State Worry questionnaire) [23]

Insomnia (Bergen Insomnia scale) [32]

Distressed personality type (Type D Scale – 14 questionnaire) [24]

Quality of life (Short-Form-12) [33]

Illness perception (Brief illness perception questionnaire) [34]

Perceived risk perception [16]

Clinical and laboratory data obtained by trained nurses (participants only)

Blood pressure (nearest 1.0 mmHg) and pulse (Connex ProBP 3400, Welch Allyn WA, NY) [26]

Body weight and height (nearest 0.1 cm with no shoes and light clothes), body mass index calculated as weight/(height)^2

Waist and hip circumference (nearest 0.1 cm) measured using a non-stretchable tape (Seca 201, Seca, Birmingham, UK).

Non-fasting blood samples analysed within 1 day

Total -, LDL- and HDL-cholesterol (Architect ci16200, reagents from Abbott Diagnostics, Abbott Park, IL)

HbAiC (Tosoh G8, reagents from Tosoh Medics Inc., San Francisco, CA)

LDL: Low-density lipoprotein; HDL: high-density lipoprotein; HbA1C: Haemoglobin A1c; ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blockers.

^aEmployed vs. unemployed or annuity on temporary or permanent disability benefit.

^bLow socio-economic status was defined by completion of primary- and secondary school only.

^cRumination is defined as repeatedly and passively thoughts about negative emotions, focusing on their symptoms of distress and worrying about the meanings of their distress.

Table II. De novo NOR-COR variables (participants only).

Variables collected from the self-report questions

Sources of health information

Family/friends, general practitioner, cardiac rehabilitation programmes, pharmacist, books/newspapers, physiotherapist, the Internet, other

Perceived needs of more information about CHD or its risk factors

Current motivation for lifestyle changes

Ranking their motivation for changing lifestyle factors (smoking cessation, exercise, weight, diet) from 1 (not at all) to 10 (very much) on a

Likert scale

Current participation in health care follow-up

Multi-disciplinary cardiac rehabilitation, general practitioner 1, 1-2, >3 times/year, physical activity/lifestyle programmes psychologist/psychiatrist, other community-based programmes

Reasons for non-attendance (not informed, organisation routines, time, distance, cost, transportation, not available, not interested)

Current perceived needs for follow-up recorded as follows: Participants were asked whether they wanted any follow-up for their coronary disease today Then rated the four preferred option(s) that they considered to be most useful to meet their goals of prevention among the following programme categories; home or centre-based nurse led programs, physiotherapist, psychologist/psychiatrist, nutritionist, SMS or telephone consultations, internet-based programs or a mobile App, multidisciplinary programme (i.e. medical doctor, nutritionist, nurse, physiotherapist). The response categories for each programme were “Yes, absolutely”, “Yes”, “Maybe”, “No” If patients wanted a programme, they were also asked to indicate the number of times per year they wanted to attend to that particular programme. It was also possible to answer “I do not need any further follow-up from the health care system for CHD”

Beliefs regarding what caused their CHD

Ranking all known coronary heart disease risk factors (age, genetic load, smoking, stress, blood pressure, etc.) from 1 (not at all) to 10 (very much) on a

Likert scale to what extent they believed that each risk factor had caused disease development

Perception and understanding of the information provided by health care workers:

The patients were asked to choose one of the following statements: (a) “I am healthy again but need to change life habits”, (b) “I am healthy again, no need to  change life habits”, (c) “I still have CHD and need to change life habits”, or (d) “I still have CHD, no need to change life habits” [21]

CHD: Coronary heart disease.

Table III. Baseline socio-demographic and medical characteristics of the NOR-COR study participants.

Variable
Mean age at index event (SD), years	63.1 (9.6)
Age <60 years, %	32.3
Age 61–74 years, %	55.5
Age >75 years, %	12.2
Women, %	21.0
Living alone, %	19.3
Low education, %	70.3
Unemployed or disability benefits	20.5
Ethnic minorities (1st and 2nd generation patients from Asia, Africa and South America)	3.0
Average time since the index coronary event (min, max), months	17.0 (2-38)
Average number of days hospitalized (min, max)	5.56 (1-42)
Prevalence of somatic and psychiatric comorbidity at index event, %
Heart failure	13.1
Periphery vascular disease	8.9
Apoplexy/transitory ischemic attacks	7.0
Chronic obstructive pulmonary disease	8.8
Chronic kidney failure	13.4
Atrial fibrillation or atrial flutter	9.4
Anxiety	3.0
Depression	6.3
Medication at discharge, %
Aspirin or anti-platelets	98.5
Statins	96.1
Beta-blockers	84.8
Antidiabetics	10.9
Insulin	4.3
ACE-inhibitors/ARB	55.3
Loop or thiazide diuretics	21.5
Calcium channel blockers	16.1
Warfarin or NOAK's	7.3
Psychotropic drugs (antidepressant or anxiolytics)	5.0

ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blockers; NOAK: novel anticoagulant drugs.

Table IV. Baseline data on coronary diagnosis, angiographic findings, interventions, risk factors and participation in the cardiac rehabilitation programme of the study participants.

Variables
Coronary diagnosis, %
Non-ST elevation myocardial infarction	49.5
ST elevation myocardial infarction	29.7
Stable or unstable coronary heart disease	20.5
Angiography findings, %
Open vessels	1.4
Atherosclerosis, no sig. stenosis	5.2
Singel-vessel disease	53.2
Multi-vessel disease	40.1
Coronary intervention, %
Percutaneous coronary intervention and stent	75.3
Percutaneous coronary intervention without stent	2.0
Coronary artery by-pass graft operation	14.4
No intervention	9.6
More than one coronary event, %	29.9
Coronary risk factors at the index event, %
Current smoking	34.8
Hypertension	43.0
Total cholesterol >4.5 mmol/l	64.3
Diabetes type 1 and 2	17.0

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