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American Journal of Critical Care. 2008;17: 232-242
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CE Article

Uncertainty and Health-Related Quality of Life 1 Year After Coronary Angiography

By Jo-Ann Eastwood, RN, PhD, CCNS, Lynn Doering, RN, DNSc, Janice Roper, RN, PhD and Ron D. Hays, PhD. Jo-Ann Eastwood is an assistant professor and Lynn Doeringis a professor and chair of acute care in the School of Nursing, and Ron D. Haysis a professor, Department of Medicine, Division of General Internal Medicine and Health Services Research, at the University of California, Los Angeles. Janice Roperis assistant chief, nurse research and education, Greater West Los Angeles Veterans Administration Healthcare.

Corresponding author: Jo-Ann Eastwood, RN, PhD, CCNS, UCLA School of Nursing, 700 Tiverton Ave, Box 951702, Los Angeles, CA 90095-1702 (e-mail: eastwood{at}ucla.edu).


   Abstract
Top
 Abstract
Review of the Literature
 Theoretical Framework
 Methods
 Results
 Discussion
 Study Limitations
 Conclusion and Clinical...
 References
 
Background Little is known about illness-related uncertainty and decreased health-related quality of life in patients undergoing initial coronary angiography or about the long-term effects of uncertainty.

Objectives To compare patients with and without high levels of uncertainty before angiography and to examine the influence of uncertainty on health-related quality of life 1 year after angiography.

Methods In a prospective, longitudinal study, measurements of perceived control, uncertainty, affective distress, and health-related quality of life were collected from 93 patients before angiography (baseline) and 1 year later. At baseline, patients were classified into high- and low-uncertainty groups by median split. At 1 year, analysis of variance was used to compare health-related quality of life and psychological outcomes in the 2 groups, and multiple linear regression with stepwise entry was used to identify independent determinants of health-related quality of life.

Results Compared with patients with low baseline uncertainty, patients with high baseline uncertainty had higher levels of anxiety and depression and lower levels of perceived control and health-related quality of life 1 year after angiography. Baseline health-related quality of life, uncertainty, and life stress accounted for 54% of the variance in health-related quality of life, even when angiographic outcome was controlled for (P < .001). Baseline uncertainty was independently associated with health-related quality of life (β = –0.25; 95% confidence interval, –9.40 to –0.05; P = .02).

Conclusions At initial angiography, high levels of uncertainty about illness portend negative health-related quality of life outcomes up to 1 year later.

Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your understanding of the following objectives:
  1. Describe health-related quality of life (HRQOL) and its relationship to disease trajectory
  2. Recognize the factors that have been correlated with lower HRQOL
  3. Understand the relationship of the perceived threat of coronary artery disease and the patient’s HRQOL
To read this article and take the CE test online, visit www.ajcconline.org and click "CE Articles in This Issue." No CE test fee for AACN members.

The American Heart Association1 estimates that 1.5 million cardiac catheterizations were performed in 2003, and the number is increasing every year. Diagnosis of coronary artery disease (CAD) often creates marked psychological disturbances, including anxiety, depression, and uncertainty about the future.2 Cardiac patients have indicated the need for greater social, physical, and informational support during diagnostic and revascularization procedures.3–5

Few researchers have investigated how patients fare emotionally, physically, and socially after a diagnostic angiogram. Patients awaiting revascularization procedures reported that uncertainty and fear were more disturbing than was chest pain.5–7 Focus groups revealed that patients recovering from percutaneous coronary intervention (PCI) felt a sense of powerlessness and an overwhelming feeling of uncertainty about the disease and their prognosis.8 In a more recent study,9 levels of both anxiety and depression were high before the procedure, and levels of depression were even higher 6 to 8 months later. Also, patients who have PCIs may experience other anxiety, be absent from work, and have continuing signs and symptoms.10 Although no studies have reported the role of social support after angiography, social support is associated with improved outcomes in other cardiac patients.11

Health-related quality of life (HRQOL) reflects the functional effect of an illness and its therapy from the patient’s point of view.12 Poor HRQOL has been associated with poorer outcomes, such as lower survival rates, increases in the number of hospitalizations, decreased capacity to perform activities of daily living, and decreased compliance with treatments in other populations of cardiac patients.12–15 Despite a growing interest in HRQOL in cardiac patients, HRQOL has received little attention in the context of angiography. Although evidence indicates that illness-related uncertainty is an important concern in angiography patients,7,8 the relationship between uncertainty and other psychological disturbances and to overall HRQOL has not been investigated.

Our objectives in the study reported here were to compare patients with and without high levels of uncertainty at the time of angiography (baseline) and to examine the influence of uncertainty on HRQOL 1 year later. Specifically, we hypothesized that angiography patients with higher baseline levels of uncertainty would have poorer HRQOL, including higher levels of anxiety, depression, and hostility and lower levels of perceived control and social support, and that baseline illness-related uncertainty would be associated with lower HRQOL 1 year later.


   Review of the Literature
Top
 Abstract
 Review of the Literature
Theoretical Framework
 Methods
 Results
 Discussion
 Study Limitations
 Conclusion and Clinical...
 References
 
Health-Related Quality of Life
Improvement in HRQOL is a major objective in the care of patients undergoing cardiovascular procedures.16,17 Early studies18–21 indicated that PCI improved physical function and reduced signs and symptoms, often comparable to the effects of medical or surgical intervention. Return to work has been quicker with successful PCIs than with surgical or medical treatments.18 Although survival after PCI is comparable in men and women, in the few studies22,23 in which HRQOL was explored directly, being female was correlated with impaired HRQOL after PCI.


Patients awaiting revascularization procedures report that uncertainty and fear were more disturbing than chest pain.

 

With researchers focusing solely on patients needing intervention, no reports have been published on the effect of an initial angiogram on HRQOL in patients who do not meet criteria for treatment (=50% obstructive disease). However, these patients are particularly vulnerable to anxiety and depression because few health providers offer psychological support or see such support as necessary when the results of a diagnostic procedure are not clinically significant.9 Because CAD is a chronic condition, patients often perceive diagnostic angiography as a critical life-threatening episode filled with uncertainty. Patients undergoing angiography face 2 possibilities: (1) the results will indicate a disease that is unpredictable, characterized by exacerbations, and perceived to have an inevitable downward course; or (2) the results will not explain disturbing signs and symptoms, and additional diagnostic procedures may be required.

Illness-Related Uncertainty
Research24 has shown that uncertainty has a negative effect on the quality of life of patients with diseases such as breast cancer and heart failure. For example, cancer patients with more extensive disease differed significantly from those with less extensive disease. Even years after successful treatment of breast cancer, survivors experienced a fear of recurrence that was strongly associated with increased illness, uncertainty, and emotional distress.8 Social support was influential in decreasing uncertainty and psychological distress in women with gynecological cancer.24,25 A few studies have indicated that uncertainty is an important part of the experience of heart disease, encompassing different severity levels such as heart failure,26 bypass surgery,27,28 and living with an automatic implantable cardioverter-defibrillator.29 In these studies,26–29 higher levels of uncertainty correlated with lower HRQOL. Because of the wide variation in the severity of CAD and the ever-increasing numbers of patients experiencing initial angiograms, determining the impact of uncertainty on HRQOL in this group of patients is important.


Uncertainty about an illness is the greatest single psychological stressor for patients with a life-threatening illness.

 

Social Support
In general, social support is thought to be important to cardiac patients and to be linked to HRQOL.11,30 In a cross-sectional study31 of patients undergoing cardiac catheterization, lack of social support was associated with lower HRQOL across multiple domains, including emotional, physical, social, and role domains. Further, interactions of social support with demographic characteristics, such as minority status, income, and education, suggested that some patients may be more susceptible than others to the effects of social support.

Psychological States
Perceived control and dysphorias (anxiety, depression, and hostility) have been associated with poor outcomes in cardiac patients.30–33 In most of the initial studies, the investigators focused on situational anxiety associated with catheterization. A recent report34 confirmed that anxiety while awaiting catheterization is associated with reduced HRQOL. In cardiac catheterization patients followed up for 2 years, negative emotions outweighed the benefit of positive ones in predicting survival.35 To date, no reports have been published on the role of perceived control in HRQOL among angiography patients.


   Theoretical Framework
Top
 Abstract
 Review of the Literature
 Theoretical Framework
Methods
 Results
 Discussion
 Study Limitations
 Conclusion and Clinical...
 References
 
HRQOL is a multidimensional construct that includes a patient’s perception of his or her limitations related specifically to health. Hays and Morales36 identified 2 aspects of HRQOL: (1) the impact that health has on a person’s ability to function and (2) the person’s perceived well-being in physical, mental, and social domains of life. Others37 have included perceived life satisfaction related to disease, accidents, and treatments as well as perceived well-being as part of HRQOL. Thus, HRQOL is distinguished from overall quality of life by its focus on the influence of the health-illness continuum on a person’s sense of well-being and life satisfaction.

The multidimensional aspects of HRQOL include physical, social, and psychological domains that influence a person’s perceptions. Physical functioning refers to the ability to carry out daily life activities.17 Social functioning encompasses the ability to interact with family, friends, and the community and to maintain social roles at the desired level.38

Psychological functioning refers to overall mental and emotional well-being, including both positive and negative states. Memory, alertness, ability to communicate, decision-making capabilities, and judgment are mental capabilities that constitute intellectual function.38 Well-being relies on a person’s internal subjective perception of mood states such as feeling happy, sad, depressed, anxious, energetic, or lethargic.

To provide the theoretical framework for this study, we adapted the construct of HRQOL, the uncertainty in illness theory,25,39 and the life transition theory40 (see FigureGo). A major characteristic of any transition is how people restructure their reality and resolve uncertainty after a "crucial event." A crucial event is defined as a disruption in a person’s present reality. Uncertainty is defined as the inability to determine the meaning of illness-related events.25 Uncertainty about the illness is the greatest psychological stressor for patients with life-threatening illness.24 Theorists assert that uncertainty spreads into many areas of a person’s life, dismantles the meaning of everyday events, and becomes the stimulus for disorder. If a person cannot eliminate or reduce it, uncertainty may dismantle the person’s view of self and of reality.


Figure 1
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  		Figure Theoretical framework.

Abbreviation: HRQOL, health-related quality of life.

 
However, uncertainty can be viewed as either danger or opportunity. Perceptions of danger arise when negative inferences are made. Conversely, when positive inferences are made, uncertainty is perceived as an opportunity.41 In both circumstances, people marshal coping strategies on the basis of their perceptions of threat. Uncertainty therefore triggers a new perspective on life and may influence HRQOL.25

According to these theories, a life transition will occur if the disruption of reality necessitates a reorganization or reconstruction of the existing reality.40 For this study, we assumed that the crucial event is the potential diagnosis of CAD. The impact of this disruption is multidimensional and affects patients socially, physically, and psychologically—that is, in terms of HRQOL. To regain the integrity of the self, a patient must reduce uncertainty, acknowledge that his or her reality has changed, and reconfigure the new reality.

In summary, a life transition forms a bridge from a reality disrupted through uncertainty to a newly constructed or surfacing reality.42 In our model, a patient undergoes a transition from one level of HRQOL through recovery, which may be influenced by the patient’s level of uncertainty. The restructured reality is reflected by the level of HRQOL that the patient attains when the uncertainty is partially or wholly resolved.


   Methods
Top
 Abstract
 Review of the Literature
 Theoretical Framework
 Methods
Results
 Discussion
 Study Limitations
 Conclusion and Clinical...
 References
 
In this prospective, longitudinal study, patients were studied before (4 days to 1 week) elective angiography and 1 year after the procedure. Measures included angiographic outcome (diagnosis of CAD or no CAD); HRQOL; levels of uncertainty, angina, and dysphoria; perceived control; social support; and stressful life events during the year after angiography.

Patients and Setting
All consecutive patients who were scheduled for initial elective diagnostic coronary angiography at 2 academic hospitals and 2 community hospitals, gave permission to be contacted about research participation, and subsequently gave informed consent were prospectively enrolled from cardiologists’ offices before the angiography. The enrollment period was 14 months. On the basis of moderate to large effect sizes (Cohen d = 0.70) in comparisons of uncertainty and HRQOL in patients who had revascularization or other chronically illness,43 a sample size of 100 was targeted to provide a power of 80% at {alpha} = .05, 2-tailed). Patients were included in the study if they were 18 years or older and able to read and write English. Exclusion criteria were significant debilitating comorbid conditions (ie, severe respiratory disease, renal failure requiring dialysis, or current malignant neoplasm), history of coronary revascularization, and significant uncorrected coronary valve disease. Of the 103 patients who met these criteria, 100 were enrolled, and 93 completed the 1-year follow-up.


Even patients without coronary artery disease show significant reductions in some aspects of health-related quality of life.

 

Instruments
  HRQOL Measures.   General HRQOL was measured by using the Short-Form 36, version 2 (SF-36v2), of the Medical Outcomes Health Survey. This instrument yields 2 composite scores. The physical health composite summary is a score of the items used to measure physical functioning, role functioning, bodily pain, and general health measures; the mental health composite summary is a score of the items used to measure vitality, social functioning, role functioning (emotional), and mental health.44 Higher scores indicate better HRQOL.45 In this study, the Cronbach {alpha} coefficients of the mental health and physical health composite summary scores were 0.68 and 0.78, respectively.

The Quality of Life Index–Cardiac III (CQLI-3)16,46 was used to examine disease-specific HRQOL. The CQLI-3 is divided into 2 sections of 36 items each. One section measures satisfaction with the domains of physical function, socioeconomic status, psychological/spiritual state, and family life; the second section measures the importance of the domains. Scores on each scale range from 0 to 30; high scores indicate high satisfaction or importance. In this study, the Cronbach {alpha} coefficient was 0.94 at baseline and 0.98 at 1 year.

The Seattle Angina Questionnaire47–49 was used to measure intensity of anginal pain. The questionnaire is a self-administered disease-specific measure for patients with coronary artery disease. It consists of 19 questions used to quantify 5 clinical domains: physical limitation, anginal stability, anginal frequency, treatment satisfaction, and disease perception/QOL. This instrument has well-established psychometric properties and corresponds well to the Canadian Cardiovascular Society Classification. The disease perception/QOL scale, which was used in this study, is used to characterize a patient’s perception of the impact of CAD on his or her quality of life. Higher scores on the questionnaire’s subscales indicate better levels of functioning.48,49 In this study, the Cronbach {alpha} coefficient was 0.88 at baseline and 0.92 at 1 year.


High levels of uncertainty and low levels of perceived control markedly reduce quality of life and endure at least 1 year.

 

  Psychosocial Measures.   The Uncertainty in Illness Scale-Community43 was used to measure uncertainty in illness. This instrument consists of 23 items that patients rate on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Scores on the scale range from 23 to 115, with a midrange score of 69; higher scores indicate higher perceived uncertainty. In this study, the Cronbach {alpha} coefficient was 0.89 at baseline and 0.94 at 1 year.

Perceived control was measured by using the Cardiac Attitudes Index. This index is used to measure a patient’s perception of control when faced with cardiac disease. The instrument has items related to both the patient’s own perception of control and to his or her perception of the degree to which his or her family members feel control. Higher scores on the Cardiac Attitudes Index indicate higher feelings of control. A total of 19 belief statements are used to measure perceived control and its converse, helplessness, in the context of cardiac disease. Patients rate their agreement with 15 statements on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Four statements are rated on a similar 7-point scale.50 In this study, the Cronbach {alpha} coefficient was 0.36 at baseline and 0.86 at 1 year.

The Multiple Affect Adjective Check List51 was used to measure dysphoria (ie, symptoms of anxiety, hostility, and depression). The checklist is used to assess emotional or psychological distress and is sensitive in patients with cardiac disease. The list consists of 132 alphabetically arranged adjectives; patients check the words that describe their current feelings. Higher scores correspond to higher levels of distress. Scores higher than community norms for anxiety (>7), depression (>11), and hostility (>7) are considered consistent with increased dysphoria.51 Overall dysphoria scores are generated by summing the scores of the individual scales. In this study, the Cronbach {alpha} coefficient was 0.94 at baseline and 0.95 at 1 year.

The Perceived Social Support Scale52 was used to measure patients’ subjective assessment of social support from 3 sources: family, friends, and significant others. The tool consists of 12 items that patients rate on a 7-point Likert scale ranging from 1 (very strong disagreement) to 7 (very strong agreement). Possible scores range from 12 to 84; higher scores indicate greater support.52 In this study, the Cronbach {alpha} coefficient was 0.93 at baseline and 0.95 at 1 year.

The Life Events Stress Test is a checklist of stressful life events.53 It lists 41 life events (eg, death of a spouse or child, divorce, incarceration, job loss), and patients indicate whether any of the events occurred in their lives in the previous 12 months. The test has been used to quantify stressful life events in other cardiac patients.54 In this study, the Cronbach {alpha} coefficient was 0.73 at baseline and 0.67 at 1 year.

Procedures
Approval for the study was obtained from the institutional review boards at all study sites. For each patient who was scheduled for an initial diagnostic angiogram, permission to approach the patient was obtained by office nurses, and informed consent was obtained by a single nurse researcher (J.A.E.). Each patient was interviewed as early as possible to confirm eligibility status and collect demographic data. Each patient was given a packet of self-administered tools with instructions to complete the tools and return the prestamped and preaddressed packets to the investigator by mail before the patient’s procedure. Packets including all the instruments administered before the angiogram, along with written instructions, were mailed to patients 1 year after the procedure, and individual telephone follow-up was provided to promote compliance.

After initial angiography, patients were classified into 2 naturally occurring groups: those who had CAD and those who did not. Of the 100 subjects who received an angiogram, 44 had no clinically significant CAD. The 66 patients classified as having CAD had angiographic evidence of occlusive disease (blockage = 50%), critical disease of the left main coronary artery, or diffuse microvascular disease, or had definitive interventional, surgical, or medical therapy for CAD.55

Data Analysis
Measures of central tendency were used to describe the sample. Because cutoffs for severity in uncertainty scores have not been determined and because the median score (64) in this study approximates the midpoint of all possible scores (69), a median split was used to divide patients divided into groups with high and low uncertainty scores. For comparisons of patients with abnormal (CAD) and normal (no CAD) angiographic findings and of patients with high and low baseline uncertainty, t tests were used for continuous variables, and {chi}2 analysis was used for categorical variables. The relationship between uncertainty at baseline and HRQOL at 1 year was determined by using continuous linear regressions with stepwise elimination for each HRQOL measure (SF-36v2, mental and physical health composite summaries, CQLI-3, and Seattle Angina Questionnaire). First, the relationships between demographic and psychosocial variables at baseline and each HRQOL measure at 1 year were assessed by using bivariate correlational statistics (Pearson r for continuous variables and {chi}2 for categorical variables). Variables associated at 1 year at the P = .10 level were included in the regression equation. For each measure, baseline scores were entered first into the equation, then demographic variables and psychosocial variables were entered as separate blocks, and then angiographic outcome status (CAD or no CAD) and baseline uncertainty. Standard entry (.05) and deletion criteria (.10) were used. SPSS 13.0 (SPSS Inc, Chicago, Illinois) was used for all analyses.


   Results
Top
 Abstract
 Review of the Literature
 Theoretical Framework
 Methods
 Results
Discussion
 Study Limitations
 Conclusion and Clinical...
 References
 
Characteristics of the Sample
Characteristics of the sample are presented in Table 1Go. Significant differences between patients with and without CAD were minimal. Patients with CAD were older (P = .02), and a greater percentage of patients without CAD were taking antidepressants (P = .01). Of the 56 patients with CAD, 23 (41%) had angioplasty with stent implantation in at least one coronary artery. The remaining treatment options for patients with CAD were coronary artery bypass surgery (n = 10; 18%), medical treatment (n = 17; 30%), and elective medical management despite a recommendation for bypass surgery (n = 6; 10%). During the year after angiography, 8 patients had emergency department visits for heart problems, 2 had open-heart surgery, and 7 had angioplasty with stent implantation.


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  		Table 1 Clinical and demographic characteristics by angiographic outcome (n = 100)a

 
Dysphoria and Social Support
Patients with and without CAD differed by angiographic outcome on some psychosocial variables before the procedure. Overall, patients with no angiographic evidence of CAD reported more distress before the procedure (Table 2Go). Specifically, at baseline, these patients tended to have higher illness-related uncertainty (P =.05), and they reported feeling less control over their health (P = .03). Also, they had lower scores on the mental health composite summary (P = .03) and lower overall disease-specific HRQOL scores (P = .02) than did patients with CAD. At 1 year after angiography, however, these differences had all but disappeared. At 1 year, no differences according to angiographic outcome existed in the number of stressful events or in levels of perceived control, anxiety, hostility, depression, or HRQOL (Table 2Go). The only between-group difference was a trend toward lower perceived control in the patients without CAD (P = .05).


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  		Table 2 Psychosocial differences at baseline and 1 year after angiography in patients with and without coronary artery disease (n = 93)

 
High vs Low Uncertainty
Groups with high and low levels of uncertainty were compared for demographics and clinical differences at baseline (Table 3Go) and for psychosocial differences 1 year later (Table 4Go). Patients with higher baseline uncertainty were more likely to be female and tended to be younger and more likely to have angina than were patients with lower uncertainty. Other baseline demographic and clinical characteristics did not differ between the 2 groups. Patients with higher uncertainty at baseline had significantly lower levels of perceived control, higher levels of anxiety, and higher levels of depression at 1 year than did patients with lower uncertainty at baseline.


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  		Table 3 Demographic and clinical differences in patients with low versus high uncertainty before angiographya

 

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  		Table 4 Psychosocial differences at 1 year after angiography in patients with low and high levels of uncertainty before the procedure (n = 93)

 
Determinants of HRQOL
Determinants of HRQOL for each relevant measure 1 year after angiography are presented in Table 5Go. Overall, the dysphorias (anxiety, hostility, depression) had limited correlation with the HRQOL measures when considered with other factors. Both baseline uncertainty and life stress during the 1 year after angiography were influential in multiple HRQOL measures. Together, baseline HRQOL, uncertainty, and life stress explained 54% of the variance in overall disease-specific HRQOL (as indicated by CQLI-3 scores), even when angiographic outcome was taken into account (P < .001). High uncertainty at baseline was predictive of lower disease-specific HRQOL (CQLI-3) 1 year later even when the status of CAD was considered. Similarly, with mental health status (as indicated by the mental health composite summary of the SF-36v2), both uncertainty and life stress contributed significantly to the explained variance of 35%. For the 2 measures that focused more directly on physical symptoms (SF-36v2 physical health composite summary and Seattle Angina Questionnaire), neither uncertainty nor life stress was a significant correlate.


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  		Table 5 Associations of uncertainty and other variables to health-related quality of lifea

 

   Discussion
Top
 Abstract
 Review of the Literature
 Theoretical Framework
 Methods
 Results
 Discussion
Study Limitations
 Conclusion and Clinical...
 References
 
Our findings provide data on the relative contribution of physical, social, and psychological domains to HRQOL in patients undergoing angiography for the first time. The psychological domain, particularly uncertainty and perceived control, and the occurrence of stressful life events may be the most important in these patients. Many descriptive studies of patients with CAD have been published. However, little longitudinal information is available on HRQOL in patients undergoing initial angiography for the diagnosis of CAD. To date, this study is the only one in which the differential effect of angiographic findings and uncertainty during the first year after initial angiography were examined.

Uncertainty
The most striking finding is that baseline uncertainty is associated with reduced HRQOL 1 year after initial angiography despite the angiographic findings and the treatment regimen. In 2 of the 4 HRQOL measures (ie, those used to measure disease-specific HRQOL and the mental health domain of general HRQOL), these differences persisted even when baseline values of HRQOL, angiographic findings, and baseline values of other related psychosocial and demographic variables were taken into account. Thus, even a patient who does not have CAD is likely to experience marked reductions in at least some aspects of HRQOL if he or she has higher levels of uncertainty about CAD before angiography. Uncertainty has been reported in other populations of cardiac patients, including those recovering from coronary artery bypass grafting and those with heart failure.26,28 Clearly, our results support the need for psychological assessment of all cardiac patients.

Our findings about the role of uncertainty in HRQOL support our theoretical framework. In Mishel’s theory of uncertainty, uncertainty can be appraised as an opportunity or a danger.25 Before angiography, patients who did not have CAD experienced higher than normative levels of anxiety. This characteristic could account for the higher levels of uncertainty we found. The high baseline uncertainty scores also may be related to a lack of information. Links between lack of information, stress, and uncertainty have been reported.24,56 In previous studies on cancer and cardiac patients, appraisal of uncertainty as a danger correlated with anxiety. It is difficult to say whether the patients with CAD perceived uncertainty as an opportunity, providing relief of symptoms and hope for the future.25 In qualitative interviews,28 patients awaiting coronary artery bypass surgery spoke of perceptions of hope to "gain a new lease on life" and to "be as good as new."


Nurses should not assume that normal findings on an angiogram are entirely benign.

 

Perceived Control
Perceived control (as indicated by CQLI-3 scores) was a significant determinant for both overall HRQOL and for the mental health component of the SF-36v2. Uncertainty and change associated with the diagnosis of CAD can seriously threaten patients’ sense of control over their well-being. The perception of less control over the illness is a significant predictor of ambiguity, a characteristic of uncertainty.57 Control over health- or illness-related events is strongly valued by patients and can have positive effects on health.41 To an extent, each person believes that outcomes can be controlled. In cardiovascular research, a challenged need for control or loss of control has been associated with the etiology of CAD.58 Ambiguity intensifies the illness situation and makes a person more vulnerable because it limits coping processes and sense of control.24 In studies on women with cancer, women who perceived their illness as uncertain but controllable made the best of the situation and used positive reappraisal strategies to create new meaning.57 From a clinical perspective, patients who lack a sense of control over their health may not be able to function successfully as partners in health care decision making with their providers. In fact, perceiving some control over one’s own health appears to be an important component in compliance with medical regimens and in recovery.58


   Study Limitations
Top
 Abstract
 Review of the Literature
 Theoretical Framework
 Methods
 Results
 Discussion
 Study Limitations
Conclusion and Clinical...
 References
 
The study had both limitations and strengths. Because of the research question, we evaluated naturally occurring groups (patients with and without CAD as determined by angiography) rather than randomly assigned groups. To mitigate underlying differences in the groups, we used multivariate techniques that allow control of inherent group differences. Because patients were aware that they were scheduled for angiography when they completed the initial questionnaires, their initial responses could have been influenced. During the first year, treatment options for the group with CAD varied from medical therapy to coronary artery bypass surgery, which could have influenced these patients’ subsequent HRQOL. The enrollment of equal numbers of women and men reduced the likelihood of sex bias in our sample.


   Conclusion and Clinical Implications
Top
 Abstract
 Review of the Literature
 Theoretical Framework
 Methods
 Results
 Discussion
 Study Limitations
 Conclusion and Clinical...
References
 
Major improvements in technology have greatly increased the outcomes for patients with CAD. However, the psychological needs of patients faced with the potential diagnosis of CAD have been ignored. Our findings confirm the hypothesis that the possibility of CAD alone, irrespective of the ultimate diagnosis, is associated with changes in a patient’s perspective of his or her own health and that negative psychological states, specifically high levels of uncertainty and low levels of perceived control, contribute significantly to reduced HRQOL. These relationships are sufficiently strong to persist for at least 1 year after the initial angiography. Therefore, nurses and other clinicians should not assume that normal angiographic findings (ie, no CAD) are entirely benign. No matter what angiography indicates, any patient who undergoes this procedure requires psychological assessment and follow-up to ensure that HRQOL remains stable. Nurses are in a unique position to identify patients who may need psychological support and information while preparing for the possible diagnosis of CAD and to institute clinical protocols to ensure that all patients are assessed and followed up, if needed. Further study is needed to test interventions to prevent negative psychological and HRQOL outcomes both in patients with and patients without angiographic evidence of CAD.


   ACKNOWLEDGMENTS
 
This research was done at the School of Nursing, University of California, Los Angeles. Final data collection was completed during a postdoctoral fellowship at the Greater West Los Angeles, Veterans Administration Health Center. We thank the Greater West Los Angeles Veterans Administration Health Center, the School of Nursing for the Diane Matoff Mentorship Award, and Gamma Tau Chapter of SigmaThetaTau.

FINANCIAL DISCLOSURES
None reported.

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   REFERENCES
Top
 Abstract
 Review of the Literature
 Theoretical Framework
 Methods
 Results
 Discussion
 Study Limitations
 Conclusion and Clinical...
 References
 

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