Optimistic ACS Patients Less Likely to Be Readmitted: GRACE

Deborah Brauser

December 09, 2015

BOSTON, MA — Holding onto hope after a hospitalization for MI or unstable angina may improve both behavioral and clinical outcomes, new research suggests[1].

The observational Gratitude Research in Acute Coronary Events (GRACE) study showed that participants who had high scores on a measure of optimism 2 weeks after experiencing an ACS had significantly greater accelerometer-measured physical activity (P=0.02) and fewer cardiac readmissions (P=0.006) 6 months later vs those with lower levels of optimism.

Although the investigators had hypothesized that having strong feelings of gratitude would also affect physical activity and readmissions, these associations were not statistically significant. Also, there were no significant associations between optimism or gratitude and prognostic biomarkers of inflammation or mortality risk, such as IL-6 and N- terminal pro-B-type natriuretic peptide (NT-proBNP).

Lead author Dr Jeff C Huffman (Harvard Medical School, Boston, MA) told heartwire from Medscape that the differences between optimism and gratitude may be due to the former pushing individuals to concentrate on the future, while the latter focuses on past and current events.

"This shows that not all positive thoughts and feelings are alike. With optimism there's a feeling of motivation and confidence moving forward. But with gratitude, individuals are less likely to think, 'Okay, what am I going to do in the future?' It may not prompt them to take action," said Huffman.

The findings were published online November 8, 2015 in Circulation: Cardiovascular Quality and Outcomes.

Positive Psychological Factors

Approximately 20% of post-ACS patients "will be hospitalized for ischemic heart disease or suffer mortality within the next year," write the investigators.

"For people who have a major heart event, many really thrive afterward and they're able to change their lives. But others have a hard time. We wanted to try to figure out what some of the factors are that might be associated with people doing well or not well," said Huffman. "And one of the areas that has been understudied is the effect of psychological factors, especially positive psychological factors, after heart problems."

In GRACE, 212 patients were initially enrolled while being hospitalized for an ACS between September 2012 and January 2014. At enrollment, Physical Activity Recall (PAR) Scale interviews were conducted for all participants and sociodemographic and medical data were gathered.

Two weeks' posthospitalization (baseline), the investigators collected blood for biomarker analysis and administered several self-report measures to 164 of the participants (84% men; mean age 61.5 years).

Optimism, which was defined by the researchers as "a general expectation that the future will be favorable," was measured by the Life Orientation Test–Revised (LOT-R). Gratitude, which was defined as "a disposition toward appreciating and being thankful for people, events, and experiences in one's life," was measured by the Gratitude Questionnaire-6 (GQ-6).

In addition, the Patient Health Questionnaire-9 was used to assess depression and the Hospital Anxiety and Depression Scale anxiety subscale (HADS-A) was used to assess anxiety.

Steps Increased, Hospitalization Decreased

The primary outcome was physical activity at the 6-month follow-up (n=153), as measured in steps per day by an accelerometer — which was given to the patients to wear 2 weeks prior. At the 6-month follow-up, self-reports were also readministered and new blood samples were collected.

"We measured four commonly studied prognostic markers associated with inflammation: high-sensitivity C-reactive protein, IL-6, tumor necrosis factor-alpha (TNF-ɑ), and soluble intracellular adhesion molecule-1 (sICAM-1)," write the investigators, adding that NT-proBNP was also assessed.

Fully adjusted models, which controlled for social and medical variables and for depression and anxiety, showed that baseline optimism on the LOT-R was significantly associated with increased steps per day at 6 months. However, baseline gratitude on the GQ-6 showed no associations on any of the models used.

There were also no significant associations for steps and either gratitude or optimism between men and women or between white and nonwhite participants.

During the 6 months after the baseline visit, 17% of the patients had a cardiac readmission and 21% had a readmission for any cause. Baseline optimism was significantly associated with decreased rates of both cardiac readmissions (adjusted hazard ratio [HR] 0.92, 95% CI 0.86–0.98; P=0.006) and nonelective all-cause readmissions (adjusted HR 0.94, 95% CI 0.89–1.0; P=0.04).

In addition, "each point on the LOT-R was associated with an 8% reduction in risk of [cardiac] rehospitalization," report the researchers.

Although optimism was associated with high-sensitivity C-reactive protein, sICAM-1, and TNF-ɑ after adjustment for age and sex (P=0.02 for all three comparisons), the associations were no longer significant after full adjustments, including for depression and anxiety. Baseline gratitude was associated only with TNF-ɑ (fully adjusted, P=0.04).

Can Optimism Be Taught?

"This was the first study to concurrently examine the effects of multiple positive psychological constructs on outcomes in patients with ACS," write the investigators.

"Our finding that higher optimism predicts greater increases in objectively measured activity has substantial clinical relevance given that increasing physical activity after an ACS is associated with fewer recurrent events," they write, adding that the finding of fewer readmissions is also important to clinicians.

On the other hand, finding no significant associations for gratitude (other than with 6-month TNF-ɑ) show that "it is important to examine specific psychological constructs within the field of psychological well-being."

"It was interesting that the beneficial effects of optimism were above and beyond the negative effects of depression or anxiety," noted Huffman. "There seems to be something unique and additional about feeling optimistic above feeling not depressed."

He said that one thing the study did not examine was whether it's possible to help patients to feel more optimistic. "Are you just an optimist? Is that just how you're built? Or can something be done? And if so, will doing that help them to be more physically active or hospitalized less?" asked Huffman. "The answers aren't known yet, but obviously these are the really important next questions."

The study was funded by grants from the John Templeton Foundation and the National Institutes of Health, with selected biomarker analysis supported in part by Harvard Catalyst Program and Singulex. Huffman and the coauthors report no relevant financial relationships.

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