RU2794026C1 - Method for determining the psychosocial adaptation of patients with coronary heart disease to chronic heart failure - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to cardiology and psychiatry, and can be used to determine the psychosocial adaptation of patients with coronary heart disease to chronic heart failure (CHF). The level of education is determined. The clinical condition is assessed in CHF according to the SHOKS scale. An ECHO-KG is performed and the Simpson left ventricular ejection fraction is determined, as well as the presence of concomitant atrial fibrillation. The following are revealed: the intake of anticoagulants, the presence of comorbid pathology, and the patient’s compliance to the prescribed treatment. A survey is conducted using the questionnaire and the psychological status of the patient is determined. Next, the identified characteristics in points in accordance with table 1 contained in the description are evaluated. All points are summed up. With a sum of 0–17 points, the patient is considered adapted, with a sum of 18–35 points the patient is considered conditionally adapted, with a sum of 36–53 points the patient is considered not adapted.

EFFECT: method provides an increase in the level of psychosocial adaptation to CHF, improving the effectiveness of its secondary prevention in patients with coronary heart disease by evaluating the most significant characteristics.

1 cl, 1 tbl, 3 ex

Description

The invention relates to the field of medicine, namely cardiology and psychiatry, and can be used to assess the influence of factors such as social status, psychological characteristics of the patient and the clinical course of the underlying disease on the psychosocial adaptation of patients with coronary heart disease (CHD) to chronic heart failure.

Chronic heart failure (CHF) is one of the most common complications of all cardiovascular diseases (CVD), which largely determines their course and prognosis [McDonagh T.A, Metra M., Adamo M., et all..2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. European Heart Journal, Volume 42, Issue 36, 21 September 2021, Pages 3599-3726, https://doi.org/10.1093/eurheartj/ehab368]. On the territory of the Russian Federation (RF), the prevalence in the population of CHF in different regions varies from 7 to 10% of cases, of which the proportion of the population of verified clinically pronounced CHF (II-IV FC) increased from 4.9% to 8.8%. The prevalence of severe CHF (III-IV FC) increased from 1.2% to 4.1% of cases [Fomin I.V. Chronic heart failure in the Russian Federation: what we know today and what we must do. Russian journal of cardiology. 2016;(8):7-13. DOI: 10.15829/1560-4071-2016-8-7-132].

The significant prevalence of CHF and its impact on the prognosis of CVD makes the problem of the disease not only medical, but also social. Of great relevance is the study of psychosocial aspects of cardiovascular diseases, evaluating their impact on the development and prognosis of the underlying disease. [Pogosova N.V., Boytsov S.A., Oganov R.G., Yufereva Yu.M., Kostyuk G.P., Kursakov A.A., Ausheva A.K., Vygodin V.A. Clinical and epidemiological program for the study of psychosocial risk factors in cardiology practice in patients with arterial hypertension and coronary heart disease (COMETA): first results of a Russian multicenter study. Cardiology. 2018;58(9):47-58. DOI: 10.18087/cardio.2018.9.10171]. The existing statistics show that 31% of patients are re-hospitalized within 30 days after discharge from the hospital, another 11% within 90 days, and also 11% by the 180th day. During the year, 60% of patients are re-hospitalized [Arutyunov A. G., Rylova A. K., Arutyunov G. P. Register of hospitalized patients with circulatory decompensation (register of the Pavlovsk hospital). Message 2. Clinical significance and prognostic role of some parameters determined during physical and instrumental examination of patients with circulatory decompensation. Journal of Heart Failure. 2014;15(2):67-75.].

CHF decompensation is the reason for the hospitalization of every second patient (49%) in medical organizations with cardiology departments, and the diagnosis of CHF appears in 92% of patients hospitalized in such hospitals [Cleland JG, Swedberg K, Cohen-Solal A, Cosin-Aguilar J, Dietz R, Follath F et al. The Euro Heart Failure Survey of the EUROHEART sur-vey program. A survey on the quality of care among patients with heart failure in Europe. The Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. The Medicines Evaluation Group Center for Health Economics University of York. Eur J Heart Fail. 2000;2(2):123-32].

Among the reasons for repeated hospitalizations, an important role is played by the patient's personal characteristics, psychological and psychiatric characteristics and the course of the underlying disease [Mareev V.Yu., Fomin I.V., Ageev F.T., Begrambekova Yu.L., Vasyuk Yu.A. , Garganeeva A.A., Gendlin G.E., Glezer M.G., Gautier S.V., Dovzhenko T.V., Kobalava Zh.D., Koziolova N.A., Koroteev A.V., Mareev Yu.V., Ovchinnikov A.G., Perepech N.B., Tarlovskaya E.I., Chesnikova A.I., Shevchenko A.O., Arutyunov G.P., Belenkov Yu.N., Galyavich A. S., Gilyarevsky S.R., Drapkina O.M., Duplyakov D.V., Lopatin Yu.M., Sitnikova M.Yu., Skibitsky V.V., Shlyakhto E.V. Clinical guidelines OSSN - RKO - RNMOT. Heart failure: chronic (CHF) and acute decompensated (ADHF). Diagnosis, prevention and treatment. Cardiology. 2018;58(6S):8-158. https://doi.org/10.18087/cardio.2475].

The psychological portrait of a patient with CVD has a number of features that are made up of premorbid personality traits and the severity of the clinical course of the disease. Characteristic personality traits in the form of emotional lability, irritability, anxious suspiciousness, compulsiveness. The presence of CVD in these patients leads to an aggravation of personal characteristics, the emergence of negative affective states, the development of mental maladjustment, manifested by irritability. In this regard, vegetative manifestations of the disease manifest, tolerance to stressful situations decreases, a “vicious circle” is formed, which ultimately worsens the course and prognosis of CVD. Patients with coronary artery disease who have had myocardial infarction are most susceptible to affective disorders. For persons whose character is dominated by anxiety, suspiciousness, rigidity, a tendency to cardiphobic and hypochondriacal reactions to a heart attack is characteristic, expressed in constant fear of cardiac arrest, sudden death, excessive fixation on the state of health, exaggeration of the objective symptoms of the disease. To date, the personal characteristics of patients with CHF have not been studied enough [Novikova I.A., Solovyov A.G., Sidorov P.I. Psychological features of patients with cardiovascular pathology. Russian journal of cardiology. 2004;(1):28-32].

Currently, there are many diagnostic tools that allow assessing changes in the patient's social status, his psychological, psychiatric and personality characteristics, as well as the severity of the underlying disease. With a variety of existing assessment methods, a holistic approach to understanding the adaptation / adaptive potential of such a patient has not been formed. With the existing variety of methods, it is difficult for a doctor to choose a single method that would clearly assess the patient's adaptive capabilities to the disease and take the necessary therapeutic / preventive actions. It is important to note that the structure of each large medical organization provides for the position of a clinical psychologist, psychiatrist / psychotherapist [Order of the Ministry of Health of the Russian Federation dated September 16, 2003 N 438 "On psychotherapeutic assistance", Order of the Ministry of Health and Social Development of Russia dated May 17, 2012 N 566n (as amended on February 1, 2022 ) “On Approval of the Procedure for Providing Medical Care for Mental and Behavioral Disorders”]. The role of these specialists in cardiorehabilitation measures for patients with CHF can hardly be overestimated.

To assess the psychological and psychiatric characteristics of the patient, the following are used: an abbreviated multifactorial questionnaire for personality research, a clinical questionnaire for identifying and assessing neurotic conditions (K.K. Yakhin, D.M. Mendelevich), a 14-point scale for identifying personality type D (DS14), Mini Mental Status Assessment (MMSE). To assess the awareness of the disease, compliance and quality of life, the Morisky-Green questionnaire, the Minnesota questionnaire for the quality of life of patients with CHF (MLHFQ) are used - for patients with CHF, the questionnaire "Quality of life of a patient with arrhythmia" (R.A. Libis), a short form of assessment health (English Medical Outcomes Study-Short Form, abbr. MOSSF-36). In order to assess the patient's social status and social support, questions about the patient's social status are used, and the level of support from others is also assessed (multidimensional social support perception scale - MSPSS; D. Zimet; adaptation by V.M. Yaltonsky, N.A. Sirota).

The main disadvantage of the proposed tools is the time spent by the interviewer (clinical psychologist / attending physician) when working with the patient, as well as the complexity of their processing and interpretation of the results. On average, when working with a patient, it takes from one and a half to two hours, provided that the patient's condition allows for questioning. Further analysis and interpretation of the results, which are an extremely time-consuming process. The time that is ultimately spent on one patient is not always available to the interviewer. The attending physician, in turn, does not have the opportunity to fully implement these actions.

The objective of the claimed invention is the development of a specialized questionnaire that allows to assess the degree of violation of the psychosocial adaptation of a patient with coronary artery disease to CHF and recommend an adequate rehabilitation approach based on the severity of the maladaptive process.

In the process of cardiorehabilitation measures, depending on the severity and severity of the detected disorders, such specialized specialists as a clinical psychologist, psychotherapist, psychiatrist, as well as a cardiologist/therapist take part.

The technical result to which the present invention is directed is to increase the level of psychosocial adaptation to chronic heart failure to improve the effectiveness of its secondary prevention in patients with coronary heart disease, which in turn allows us to recommend an adequate rehabilitation approach based on the severity of the maladaptive process.

The specified technical result is achieved by the fact that a survey is conducted on a questionnaire followed by an assessment of the social status, psychological and psychiatric characteristics of the patient's personality, the clinical course of the disease, the peculiarity is that the questionnaire includes 3 blocks, each block includes from 1 to 13 questions with response scales , allowing to translate the subjective opinion of the patient into digital values by summing up the answers to all 3 blocks and with values of 0 -17 points the patient is considered adapted, with 18-35 points the patient is conditionally adapted, a consultation with a clinical psychologist is required, with 36 - 53 points the patient is not adapted / maladjusted, consultation of a psychiatrist, psychotherapist is required.

Implementation of the invention.

The proposed questionnaire consists of 19 statements and is divided into 3 blocks, which are the most important for patients with CHF: social status, clinical course of the disease, psychological status of the patient. Each block includes from 1 to 13 questions (Table 1).

Table 1 - Questionnaire for assessing the psychosocial adaptation of patients with coronary heart disease to chronic heart failure Block Question Answer 0 points 1 point 2 points 3 points social status The level of education higher Below the highest Clinical course Scale for assessing the clinical condition in CHF (SHOKS), points up to 3.5 3.5 - 5.5 5.5 - 8.5 over 8.5 Ejection fraction Saved Intermediate Reduced Associated atrial fibrillation (AF) No Yes Taking anticoagulants (if AF is present) Yes No Comorbid pathology No Yes Strictly adhere to the prescribed treatment Yes Almost always Not always No Psychological status You notice memory impairment. You find it difficult to concentrate
(0-slightly, 3 pronounced) 0 1 2 3 Have you begun to notice that you forget about recent events, have you become scattered, is it more difficult for you to remember new information?
(0-never,
3 constantly) 0 1 2 3 Rate the quality of your sleep
(0 - excellent, 3 - unsatisfactory) 0 1 2 3 You notice that. former interests do not bring pleasure?
(0-slightly, 3 pronounced) 0 1 2 3 You experience a constant feeling of restlessness and anxiety
(0-never,
3 constantly) 0 1 2 3 You are often in a bad mood and irritable
(0-never,
3 constantly) 0 1 2 3 Do you notice a decrease in daily labor (domestic) activity, become less energetic and get tired quickly?
(0-never,
3 constantly) 0 1 2 3 Do you prefer loneliness to a noisy company?
(0-never,
3 constantly) 0 1 2 3 Do you feel / feel the support of loved ones (family, relatives, friends)
(0-constant,
3 never) 0 1 2 3 Do you find it difficult to start a conversation with strangers?
(0-never,
3 constantly) 0 1 2 3 Do you often experience a feeling of "goosebumps"
tingling in the fingers, toes, ripples in the eyes, tinnitus?
(0-never,
3 constantly) 0 1 2 3 Do you think that the general state of health over the past year (0 - improved, 1 - remained the same, 2 - worsened, 3 - much worse) 0 1 2 3

Block 1 - Social status.

The questionnaire did not include information about prescribed social status. The acquired social status was assessed.

Level of education (higher - 0, lower than higher - 2).

Block 2 - Clinical course of the disease.

It is estimated according to the history of the disease, the data of an objective examination and instrumental diagnostic methods.

The assessment of the severity of the course of the underlying disease includes information on the severity of CHF:

- on a scale for assessing the clinical condition in CHF (SHOKS). (0 - up to 3.5, 1 - 3.5 - 5.5, 2 - 5.5 - 8.5, 3 - more than 8.5);

- left ventricular ejection fraction according to Simpson according to ECHO-KG data (1-preserved, 2-intermediate, 3-reduced);

- the presence of concomitant atrial fibrillation (0 - no, 2 - yes);

- regular intake of anticoagulants (in the presence of AF) (0 - yes, 2 - no);

- the presence of comorbid pathology (0 - no, 2 - yes);

For the screening assessment of treatment adherence, the following statements are included: Strictly adheres to the prescribed treatment (0 - yes, 1 - almost always, 2 - not always, 3 - no).

Block 3 - Psychological status (Psychological factors).

In the event that the patient believes that this symptom (changes in daily activities) does not exist, or it did not affect life, then “0” is circled. If the indicated symptom (changes in daily activities) is also present, circle the numbers from 1 to 3 in accordance with the severity of the symptom (changes in daily activities) in ascending order.

For the screening assessment of cognitive status, the following statements are included:

1. You notice a deterioration in memory. Difficulty concentrating (0 = slight, 3 = severe)

2. Have you begun to notice that you forget about recent events, have become scattered, is it more difficult for you to remember new information? (0 - never, 3 always)

The following statements are included for screening assessment of personality traits and signs of affective disorders:

1. Rate the quality of your sleep (0 - excellent, 3 - unsatisfactory)

2. Do you prefer loneliness to a noisy company? (0-never, 3-always)

3. Do you find it difficult to start a conversation with strangers? (0-never, 3 always)

4. Do you notice that your old interests don't bring you pleasure? (0-slightly, 3 pronounced)

5. You are often in a bad mood and irritable (0-never, 3-always)

6. Do you fully feel the support of your loved ones (family, relatives, friends)? (0 - always, 3 - never)

7. You experience a constant feeling of anxiety and anxiety (0-never, 3-always)

8. Do you notice a decrease in daily labor (domestic) activity, become less energetic and get tired quickly? (0 - never, 3 - always)

9. Do you often notice a feeling of "crawling", tingling in the fingers, toes, ripples in the eyes, noise in the ears? (0-never, 3-always)

For the screening assessment of quality of life, the following statement is included:

1. Do you think that the general state of health over the past year (0 - improved, 1 - remained the same, 2 - worsened, 3 - became much worse).

The calculation of the value for the conclusion is obtained by calculating the sum of the answers to all 3 blocks.

Interpretation of results

Sum of points Conclusion 0-17 Patient adapted 18-35 The patient is conditionally adapted (consultation of a clinical psychologist is required) 36 - 53 The patient is not adapted / disadapted (consultation of a psychiatrist, psychotherapist is required)

Clinical examples of using the questionnaire.

The proposed method for assessing psychosocial adaptation is illustrated by the following examples.

Example 1

Patient N., 64 years old. Secondary vocational education.

Main disease: IHD. Postinfarction cardiosclerosis (MI with Q wave in 2012, lateral wall of the left ventricle). CHF IIB stage, III FC.

Concomitant diseases: Chronic HP-non-associated superficial antral gastritis with increased secretion, remission phase.

Complains of shortness of breath during daily physical exertion, the appearance of edema in the legs, severe weakness, fatigue, fatigue. From the anamnesis it is known that these symptoms have been disturbing for about 8 years, in connection with them he is hospitalized at least 2 times a year. An objective examination revealed swelling of the legs, the presence of wheezing in the lower parts of the lungs. The severity of CHF in the patient according to the clinical assessment scale (SHOKS) was 8 points. The distance traveled in the test with a 6-minute walk was 210 m. ECHO-KG data: LV EF according to Simpson - 47%, diastolic dysfunction of the left ventricle.

The results of the patient's survey by blocks:

1 block - 2 points

2 block - 7 points

3 block - 20 points

The sum of points on the questionnaire proposed by the authors is 29, which indicates that the patient is conditionally adapted and needs a consultation with a clinical psychologist.

Examined by a clinical psychologist of a medical organization. When examining the personality profile using the MMPI test, high hypochondria scores of 65 T-points were revealed, indicating excessive fixation of the patient on somatic unwell-being, depression 70 T-points, reflecting a tendency to causeless feelings of tension, anxiety, dissatisfaction with oneself, hysteria 62 T-scores, signaling emotional lability, impulsiveness, drama. According to the clinical questionnaire for the identification and evaluation of neurotic states, a high level of neuroticism was demonstrated on the scales of neurotic depression, hysterical response, autonomic disorders. The results of the survey on the MSPSS scale showed a reduced level of social support from family and friends. According to the SF-36 and MLHFQ questionnaires, there is a significant decrease in the quality of life, including the physical and mental components of health. Assessment of the patient's cognitive functions using the MMSE questionnaire revealed mild cognitive impairment. The result of the Morisky-Green questionnaire showed a low level of patient compliance.

The results of the questionnaire coincide with a comprehensive assessment of a clinical psychologist, which allows including psychotherapy of the emotional state, psychocorrection of attitudes towards the disease into the program of cardiorehabilitation measures, which will be aimed at increasing the level of psychosocial adaptation to chronic heart failure, and preventing early cognitive impairment.

Example 2

Patient O., 59 years old. Higher education.

Main disease: coronary artery disease: exertional angina, FC II. Atherosclerosis of the coronary arteries: LAD stenosis 60% (according to CAG data from 2019). CHF IIA stage, FC II.

Complaints of shortness of breath with moderate physical exertion, fatigue, chest pain that occurs when walking fast for more than 500 m and climbing 2-3 floors. According to the anamnesis, the symptoms have been disturbing for about 7 years, he is hospitalized for examination. An objective examination revealed pastosity in the region of the lower extremities. The severity of CHF in the patient according to the clinical assessment scale (SHOKS) was 4 points. The distance traveled in the test with a 6-minute walk was 390 m. According to the X-ray of the chest organs, congestion in the lungs was not detected. ECHO-KG data: LV EF according to Simpson - 57%, left ventricular myocardial hypertrophy.

The results of the patient's survey by blocks:

1 block - 0 points

2 block - 5 points

3 block - 10 points

A score of 15 indicates the patient's adaptation to CHF.

He was additionally examined by a clinical psychologist. During the analysis of the patient's personality profile, no significant deviations were found on the scales of the MMPI test and the clinical questionnaire for the detection and evaluation of neurotic conditions. According to the MSPSS scale, a sufficient level of social support from family, friends and other significant persons was revealed. Mild cognitive impairment and a decrease in the patient's adherence to treatment were noted.

The answers to the questions on the questionnaire proposed by us do not contradict those on the questionnaires mentioned above. These results allow the doctor to focus on the level of patient compliance and begin the prevention of cognitive impairment.

Example 3

Patient M., 58 years old. Secondary education.

IHD: Angina pectoris, III FC. Cardiac arrhythmias: permanent form of atrial fibrillation, normosystolic form, EHRA IIb. CHF III stage, IV FC. Does not take oral anticoagulants.

Concomitant diseases: Peptic ulcer of the duodenum, not associated with H. pylori, with localization of the ulcer in the bulb in the stage of scarring.

Complaints of shortness of breath with minimal physical activity, frequent palpitations, the occurrence of pressing, squeezing pain behind the sternum when walking up to 100 m or climbing one flight of stairs, lasting no more than 10 minutes and stopping with nitroglycerin. He also notes the occurrence of dizziness, severe weakness during attacks of arrhythmia, and a decrease in daily activity. According to the objective examination: edema of the legs, the presence of wheezing to the shoulder blades, the liver is enlarged to 5 cm. The severity of CHF in the patient according to the clinical assessment scale (SHOKS) was 11 points. The distance traveled in the test with a 6-minute walk is 30 m. ECHO-KG data (LV EF according to Simpson) - 38%.

The results of the patient's survey by blocks:

1 block - 2 points

2 block - 14 points

3 block - 29 points

A score of 45 indicates that the patient is maladaptive and needs to be consulted by a psychiatrist/psychotherapist.

Examined by a clinical psychologist. When examining the patient's personality profile using the MMPI test, high hypochondria scores of 79 T-points were noted, which indicates a psychosomatic type of maladjustment with astheno-neurotic manifestations, hysteria of 74 T-points, which reflects a tendency to a rapid change of experiences, instability to stress, the desire to attract the attention of others (possibly from a close circle) and doctors to the subjective severity of CHF symptoms. According to the clinical questionnaire for the detection and evaluation of neurotic states, a high level of neuroticism was demonstrated on a scale of autonomic disorders and neurotic depression. The results of the survey on the MSPSS scale showed a low level of social support from family, friends and other significant persons. According to the SF-36, MLHFQ questionnaires, “The quality of life of a patient with arrhythmia shows a significant decrease in the quality of life, including the physical and mental components of health. The Moriskey-Green test demonstrated a low level of patient compliance. According to the results of the MMSE test, a pronounced decrease in cognitive functions was noted.

Therapist: depressive episode without psychotic symptoms. Moderate cognitive impairment, multifunctional type with memory impairment.

The results obtained indicate the need to include in the program of cardiorehabilitation measures: drug therapy for mental disorders and cognitive impairments, psychotherapy of the emotional state, psychocorrection of attitudes towards the disease, which will be aimed at increasing the level of psychosocial adaptation to chronic heart failure.

The proposed method allows assessing psychosocial adaptation to CHF, personalizes the approach to the patient and recommends appropriate measures based on the severity of the detected disorders, which will increase the patient's adaptive potential to the disease and improve the quality of secondary prevention.

Approbation of the method for assessing the psychosocial adaptation of patients with coronary heart disease to chronic heart failure was carried out on 120 patients with chronic heart failure who were hospitalized in the therapeutic department of the Kazan Medical University Clinic, the cardiology department of the Kazan City Clinical Hospital No. 7.

Claims (1)

A method for determining the psychosocial adaptation of patients with coronary heart disease to chronic heart failure (CHF), including identifying the level of education, assessing the clinical state in CHF according to the SHOKS scale, then ECHO-CG is performed and the Simpson left ventricular ejection fraction is determined, the presence of concomitant atrial fibrillation, they reveal the intake of anticoagulants, the presence of comorbid pathology and whether the patient adheres to the prescribed treatment, then by questioning according to the questionnaire contained in the description, the psychological status of the patient is determined, then the identified characteristics are evaluated in points in accordance with Table 1 contained in the description, the points are summarized and at values the sum of 0-17 points the patient is considered adapted, with 18-35 points the patient is conditionally adapted, consultation of a clinical psychologist is required, with 36-53 points the patient is not adapted, consultation of a psychiatrist, psychotherapist is required.