A study to evaluate the prevalence and determinants of stress coping strategies in heart failure patients in Poland (CAPS-LOCK-HF sub-study)

Łukasz J. Krzych1, Maciej T. Wybraniec2, Agnieszka Siennicka3, 4, 5, Belinda Lees6, Kinga Gościńska-Bis7, Maciej Wójcik8, Robert Błaszczyk8, Filip M. Szymański9, Michał Orszulak2, Błażej Michalski10, Karol Kamiński11, Grzegorz Kopeć12, Anna Hrynkiewicz-Szymańska13, Ewa A. Jankowska4, 5, 14

1Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
21st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper-Silesian Medical Centre, Katowice, Poland
3Department of Physiology, Wroclaw Medical University, Wroclaw, Poland
4Department of Cardiology, Centre for Heart Diseases, Military Hospital, Wroclaw, Poland
5Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
6Nuffield Department of Surgical Sciences, University of Oxford, Oxford, England
7Department of Electrocardiology, Medical University of Silesia, Upper-Silesian Medical Centre, Katowice, Poland
8Department of Cardiology, Medical University of Lublin, Lublin, Poland
91st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
10Department of Cardiology, Medical University of Lodz, Lodz, Poland
11Department of Cardiology, Medical University of Bialystok, Bialystok, Poland
12Department of Cardiac and Vascular Diseases, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
13Department of Cardiology, Hypertension and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
14Laboratory for Applied Research on Cardiovascular System, Wroclaw Medical University, Wroclaw, Poland

Address for correspondence:
Maciej T. Wybraniec, MD, PhD, 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Upper-Silesian Medical Centre,
ul. Ziołowa 47, 40–635 Katowice, Poland, tel: +48 32 359 88 90, fax: +48 32 2523032, e-mail: wybraniec@os.pl
Received: 20.04.2016 Accepted: 21.06.2016 Available as AoP: 08.07.2016

INTRODUCTION

The diagnosis of heart failure with reduced ejection fraction (HFREF) remains a considerable physical and psychological stressor [1], which triggers behavioural, cognitive, and emotional adaptation by patients. Adequate psychological response relies on a wide range of individual stress coping strategies. It has been postulated that a flexible approach with adjustment to the type of daily challenge, rather than a permanent single strategy, leads to more efficient stress coping [1].

In patients with chronic disease, emotion-oriented coping mechanisms were shown to be related to a higher prevalence of depression [2] and a lower ability to overcome heart failure (HF)-related challenges, and importantly, reduced therapy-compliance [3]. Avoidance-oriented stress coping mechanisms among patients with severe HF has been linked to a greater extent of anger, anxiety, and depression [4]. In consequence, these stress coping strategies may result in suboptimal outcomes of HF treatment. It has been proposed that a predominantly task-oriented approach, which allows patients to concentrate on lifestyle interventions and possibly suppress emotional exhaustion, may improve the outcomes of HF treatments [5].

Therefore, this current study aimed to assess the prevalence and determinants of different stress coping strategies in patients with HFREF.

METHODS

This paper is a sub-study of the CAPS-LOCK-HF study (Complex Assessment of Psychological Status LOCated in Heart Failure), which has been described in detail elsewhere [6]. Briefly, between 2012 and 2013, consecutive patients who were hospitalised or visiting outpatient clinics in 11 cardiology centres in Poland were enrolled. Inclusion criteria were as follows: > six-month documented history of HFREF, clinical stability for ≥ three months, and left ventricular ejection fraction (LVEF) < 45%. Demographic and clinical variables were obtained from medical records. A standardised Coping Inventory for Stressful Situations (CISS) was administered on hospital admission or during a routine ambulatory visit [7]. The CISS instrument assesses how individuals cope with stressful situations and has three “coping” dimensions: “Task”, “Emotion”, and “Avoidance”. The Avoidance dimension has two sub-scales: “Distraction” and “Social Diversion”.

Statistical analysis

Statistical analysis was performed using MedCalc v. 14.8.1 (MedCalc Software, Ostend, Belgium). Quantitative variables were expressed as median and interquartile range (IQR). Qualitative variables were expressed as absolute values and percentages. Between-group differences for normally distributed quantitative data were assessed using Student t-tests or analysis of variance, and Mann-Whitney U-tests or Kruskal-Wallis tests were used for non-normally distributed variables. Distribution was verified using a Shapiro-Wilk test. For qualitative variables, the Mantel-Haenszel χ2 or Fisher’s exact tests were applied. Spearman rank coefficients of correlation were calculated for appropriate quantitative data. Determinants of stress-coping mechanisms were initially evaluated by means of bivariate comparisons and analysis of correlation, and then variables with a ‘p’ value < 0.1 (and R ≥ 0.1 for correlation) were subjected to a multivariate stepwise multiple regression model. A ‘p’ value < 0.05 was considered significant.

RESULTS

The CAPS-LOCK-HF sub-study group comprised 758 patients: 159 (21%) females and 599 (79%) males. Median age (IQR) was 64 (58–71) years. The number of patients in each New York Heart Association (NYHA) class (from I to IV) were: 35 (5%), 414 (55%), 283 (37%), and 26 (3%), respectively. The majority of patients (n = 460, 61%) had an ischaemic aetiology of HF. Median LVEF was 33% (25–40%). Median duration of HF symptoms was 4 (2–10) years. Detailed characteristics of this group have been published previously [6].

The highest score in the CISS questionnaires for this group of patients was for a task-oriented approach (median; IQR: 55; 49–61 points), demonstrating that it was the most commonly used stress coping strategy. It was followed by avoidance-oriented (45; 39–50 points) and emotion-oriented (41; 34–48 points) strategies. The distraction sub-scale of the avoidance-oriented stress management strategy was more commonly used than the social diversion one (20; 16–23 vs. 16; 14–19 points, respectively).

In multiple regression analysis we found that the score for task-oriented strategies was lower for those patients with higher NYHA classes and was negatively correlated with systolic blood pressure, whereas the score for emotion-oriented strategies was higher in females, patients with higher NYHA classes, and those not taking angiotensin-converting enzyme inhibitors and/or angiotensin-receptor blockers. Higher scores for avoidance-oriented strategies were found in patients in sinus rhythm on assessment but lower in those who had a history of (any) neoplasm. A higher score in the distraction sub-scale was also found in patients with sinus rhythm on assessment and those with no history of neoplastic disease, and was independently associated with higher NYHA classes. A higher score in the social diversion sub-scale was observed in females and in patients with no history of implantable cardioverter-defibrillator implantation. The results of the regression analysis are presented in Table 1. CISS consecutive scores by NYHA class are shown in Figures 1A–E.

Table 1. Significant determinants of different stress management strategies — multivariate analysis

Figure 1. Coping Inventory for Stressful Situations (CISS) stress coping strategy by New York heart Association (NYHA) class (median and IQR); A. Task-oriented; B. Emotion-oriented; C. Avoidance-oriented; D. Distraction subscale of avoidance-oriented strategy; E. Social diversion subscale avoidance-oriented strategy

DISCUSSION

CAPS-LOCK-HF is the first large study designed to investigate the range of psychological and emotional characteristics of patients with HFREF in Poland. This current sub-study provided evidence for the high prevalence of favourable task-oriented coping strategies, followed by avoidance-oriented and emotion-oriented strategies for coping with stress due to illness.

We found an inverse relationship between NYHA class and the task-oriented approach (Fig. 1A), and conversely, a positive correlation between higher NYHA class and emotion-oriented stress management (Fig. 1B). As previously shown in a group of men with moderate HF, emotion-oriented stress coping is associated with more pronounced depressive tendencies and sense of lack of control over the disease [8]. This style of coping was also more frequently utilised by patients with diabetes type 2, which was accompanied by impaired quality of life and more pronounced depressive symptoms [9]. The symptomatology of the patients was inextricably connected with the self-rated physical functioning and subjective perception of the progression of the disease. Eisenberg et al. [10] concluded that avoidance coping, along with anxiety, was significantly related with impaired physical functioning and thereby more symptomatic disease.

The inverse relationship of task- and emotion-oriented coping and symptomatology of HF might be related to their effects on emotional status. Lewandowska et al. [11] confirmed that task-oriented management exerted a positive impact on emotions in moderate asthma, whereas avoidance-oriented coping performed better in severe forms of the disease. Also, task-oriented strategies might be more efficient in situations amenable to control, whilst an emotion-focused one may be more helpful in situations where there is less control [12]. This may explain why neoplastic disease [13] was an independent predictor of emotion-oriented coping strategies in this current analysis. The preference of emotion-oriented coping in women has been shown previously in depressive disorders, where females with depression handled stress mostly using an emotion-oriented strategy [14]. As far as avoidance coping is concerned, female participants tended to choose social interactions as a manner of lowering daily stress levels and displayed a preference for social diversion strategy.

Limitations of the study

Although the CAPS-LOCK-HF study aimed to enrol consecutive patients in each participating centre, selection bias cannot be excluded. Secondly, all applied psychological measures were by the self-reported CISS questionnaire, which may generate a potential risk of misinterpretation. As a result, our findings may not be able to be generalised beyond the study group from the participating centres. Furthermore, patients with more favourable stress management abilities might have been more inclined to participate than those who were more anxious and depressed. If so, then this may have shifted the balance towards a task-oriented approach. Finally, the cross-sectional design of the study makes it impossible to determine the causal relationship between coping style preference and symptomatic progression of HF. Accordingly, the study did not involve follow-up; thus, the relationship between stress coping strategy and treatment outcomes could not be established.

CONCLUSIONS

Patients with HFREF in Poland most commonly use favourable task-oriented coping strategies to overcome disease-related stress. The progression to more symptomatic stages of HF corresponds with a shift towards more emotion-oriented coping strategies with a potentially detrimental impact on therapy adherence. Routine evaluation of coping strategies should be considered in order to identify patients with supplementary needs for psychological support because this may improve treatment outcomes.

Conflict of interest: none declared

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