Pre Operative Stress and Anxiety in Patients Undergoing Cardiac Surgery Counselled with Structured Versus Traditional Programme
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Abstract
Background: Cardiovascular disease is one of the major public health problems that causes restricted quality of life, disability, and mortality, with high costs for the healthcare system. Cardiac surgery is a stressful life event for many patients. Failure to adapt to such a procedure leads to increased physical and psychological impairment such as anxiety, fear, depression, and pain. The aim of this study is to compare pre-operative stress and anxiety in patients undergoing cardiac surgery, counselled with structured vs traditional teaching programme. Methods: This is a quasi-experimental, single blinded two group pre and post-test design study done in the Department of Cardiothoracic and vascular surgery, Government Medical College, Kottayam. 120 patients (60 in each group) admitted in the wards in Government Medical College, Kottayam with CABG and valve disease were included in the study. The data was collected by a structured proforma and frequency, mean, median and standard deviation are used to assess the socio demographic variables and preoperative stress and anxiety among control and experimental groups. Comparison of two groups performed by t test and χ2 test Population. Results: In the present study it was found that structured teaching programme was effective in significant decrease of pre-operative stress and anxiety among patients undergoing cardiac surgery in the experimental group. Statistically significant reduction in anxiety and depression after preoperative structured teaching was found. Conclusion: We require more studies that are necessary to assess which mode of intervention is beneficial for patients and at what conditions. It is important to treat mind along with heart to get better outcomes after cardiac surgery.
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Copyright (c) 2026 Dr. Siva Ramaratnam, Dr. Sivaprasad V, Dr. Ravikrishnan J
This work is licensed under a Creative Commons Attribution 4.0 International License.
Creative Commons License All articles published in Annals of Medicine and Medical Sciences are licensed under a Creative Commons Attribution 4.0 International License.
Dr. Siva Ramaratnam, Senior Resident, Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, Kerala, India.
Senior Resident, Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, Kerala, India.
Dr. Sivaprasad V, Associate Professor, Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, Kerala, India.
Associate Professor, Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, Kerala, India.
Dr. Ravikrishnan J, Associate Professor, Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, Kerala, India.
Associate Professor, Department of Cardiovascular and Thoracic Surgery, Government Medical College, Kottayam, Kerala, India.
[1] Murray CJL, Lopez AD. Measuring the global burden of disease. N Engl J Med. 2013;369:448–57.
[2] Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics - 2014 update: a report from the American Heart Association. Circulation. 2014;129:1–268.
[3] Lindsay GM, Smith LN, Hanlon P, Wheatley DJ. Coronary artery disease patients’ perception of their health and expectations of benefit following coronary artery bypass grafting. J Adv Nurs.2000;32:1412–21.
[4] Feuchtinger J, Burbaum C, Heilmann C, Imbery C, Siepe M, Stotz U, et al. Anxiety and fear in patients with short waiting times before coronary artery bypass surgery - a qualitative study. J Clin Nurs. 2014;23:1900–7.
[5] Kittel J, Wamper U, Hinz A, Schwarz R, Karoff M. Depression in cardiac patients undergoing rehabilitation- a study for investigating the correlations between depression and occupational groups. Rehabilitation 2003; 42: 164-8.
[6] Koivula M, Tarkka MT, Tarkka M, Liappala P, Paunonenllmonen M. Fear and anxiety in patients at different time-points in the coronary artery bypass process. Int J Nurs Stud 2002; 39: 811-22.
[7] McCrone S, Lenz E, Tarzian A, Parkins S. Anxiety and depression: Incidence and patterns in patients after coronary artery bypass graft surgery. Appl Nurs Res 2001; 14: 155-64.
[8] Edell Gustafsson UM, Hetta JE. Anxiety depression and sleep in male patients undergoing coronary artery bypass surgery. Scand J Cannd Sci 1999; 13: 13-43.
[9] Duits AA, Duivenvoorden HJ, Boeke S, Taams MA, Mochter B, Krauss XH, Passchier J, Erdman RA. A structural modelling analysis of anxiety and depression in patients undergoing coronary artery bypass graft: a model generating approach. J Psychosom Res 1999; 46: 187-200.
[10] Ahlgren E, Lundqvist NA, Aren C, Rutberg H. Neurocognitive impairement and driving performance after coronary artery bypass surgery. Eur J Cardiothorac Surg 2003; 23: 334-40.
[11] Bergh C, Brkstrom M, Jonsson H, Havinder L, Johnsson P. In the eye of both patient and spouse: memory is poor 1 to 2 years after coronary bypass and angioplasty. Ann Thorac Surg 2002; 74: 689-94.
[12] Blumenthal JA, Left HS, Babyak MA, White W, Smith PK, Mark DB, Jones R, Mathew JP, Newman MF. Depression as a risk factor for mortality after coronary artery bypass surgery. Lancet 2003; 62: 604-9.
[13] Burg MM, Benedetto MC, Soufer R. Depressive symptoms and mortality two years after coronary artery bypass graft surgery (CABG) in men. Psychosom Med 2003, 65: 508-10.
[14] Rymaszewska J, Kiejna A, Hadrys T. Depression and anxiety in coronary artery bypass grafting patients. Eur Psychiatry 2003; 18: 155-60.
[15] Duits AA, Boeks S, Taams MA, Passchier J, Erdman RA. Prediction of quality of life after coronary artery bypass graft surgery: a review and evaluation of multiple recent studies. Psychosom Med 1997; 59: 257-68.
[16] Sullivan MD, LaCroix AZ, Spertus JA, Hecht J, Russo J. Depression predicts revascularization procedures for 5 years after coronary angiography. Psychosom Med 2003; 65: 229-36.
[17] Zamvar V, Williams D, Hall J, Payne N, Cann C, Young K, Karthikeyan S, Dunne J. Assessment of neurocognitive impairment after off-pump and on-pump techniques for coronary artery bypass graft surgery: prospective randomised controlled trial. BMJ 2002; 325:1268.
[18] Pignay-Demaria V, Lesperance F, Demaria RG, Frasure-Smith N, Perrault LP.Depression and anxiety and outcomes of coronary artery bypass surgery. Ann Thoracic Surg 2003; 74: 314-21.
[19] Pedersen SS, von Känel R, Tully PJ, Denollet J. Psychosocial perspectives in cardiovascular disease. Eur J Prev Cardiol. 2017;24: 108–15 This article provides an overview on psychosocial risk factors for cardiovascular disease including potential biological and behavioral pathways.
[20] Albus C, Waller C, Fritzsche K, Gunold H, Haass M, Hamann B, et al. Significance of psychosocial factors in cardiology: update 2018. Clin Res Cardiol.2019;108:1175–96.
[21] Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur Heart J. 2016;37:2315–81.
[22] Sadeghi M, Hashemi M, Sararoudi R, Merasi M, Molaeinezhad M, Shamsolketabi Demographic and psychological predictors of recovery from coronary artery bypass graft. J Educ Health Promot. 2017;6:92.
[23] Nielsen S, Giang KW, Wallinder A, Rosengren A, Pivodic A, Jeppsson A, et al. Social factors, sex, and mortality risk after coronary artery bypass grafting: a population-based cohort study. J Am Heart Assoc. 2019;8:e011490.
[24] Poole L, Ronaldson A, Kidd T, Leigh E, Jahangiri M, Steptoe A. Pre-surgical depression and anxiety and recovery following coronary artery bypass graft surgery. J Behav Med. 2017;40:249–58.
[25] Head SJ, Osnabrugge RLJ, Howell NJ, Freemantle N, Bridgewater B, Pagano D, et al. A systematic review of risk prediction in adult cardiac surgery: considerations for future model development. Eur J Cardio-thoracic Surg. 2013;43:e121–9.
[26] Poole L, Leigh E, Kidd T, Ronaldson A, Jahangiri M, Steptoe A. The combined association of depression and socioeconomic status with length of post-operative hospital stay following coronary artery bypass graft surgery: data from a prospective cohort study. J Psychosom Res. 2014;76:34–40.
[27] Young S, Linden W, Ignaszewski A, Con A, Terhaag S, Campbell T. Psychosocial and medical predictors of 1-year functional outcome in male and female coronary bypass recipients. Hear Mind. 2019;3:113.
[28] Joseph HK, Whitcomb J, Taylor W. Effect of anxiety on individuals and caregivers after coronary artery bypass grafting surgery. Dimens Crit Care Nurs. 2015;34:285–8.
[29] Tully PJ, Winefield HR, Baker RA, Denollet J, Pedersen SS, Wittert GA, et al. Depression, anxiety and major adverse cardiovascular and cerebrovascular events in patients following coronary artery bypass graft surgery: a five-year longitudinal cohort study. Biopsychosoc Med. 2015;9:14.
[30] Grossi G, Perski A, Feleke E, Jakobson U. State anxiety predicts poor psychosocial outcome after coronary bypass surgery. Int J Behav Med. 1998;5:1–16.
[31] Steptoe A, Kivimäki M. Stress and cardiovascular disease: an update on current knowledge. Annu Rev Public Health. 2013;34:337–54.
[32] Ancona C, Agabiti N, Forastiere F, Arca M, Fusco D, Ferro S, et al. Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy. J Epidemiol Community Health. 2000;54:930–5.
[33] Benedetto U, Albanese A, Kattach H, Ruggiero D, De Robertis F, Amrani M, et al. Smoking cessation before coronary artery bypass grafting improves operative outcomes. J Thorac Cardiovasc Surg. 2014;148:468–74.
[34] Arthur HM, Daniels C, McKelvie R, Hirsh J, Rush B. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery: a randomized, controlled trial. Ann Intern Med. 2000;133:253–62.
[35] McCann M, Stamp N, Ngui A, Litton E. Cardiac prehabilitation. J Cardiothorac Vasc Anesth. 2019;33:2255–65.
[36] Auer CJ, Glombiewski JA, Doering BK, Winkler A, Laferton JAC, Broadbent E, et al. Patients’ expectations predict surgery outcomes: a meta-analysis. Int J Behav Med. 2016;23:49–62.
[37] Barefoot JC, Brummett BH, Williams RB, Siegler IC, Helms MJ, Boyle SH, et al. Recovery expectations and long-term prognosis of patients with coronary heart disease. Arch Intern Med. 2011;171: 929–35.
[38] Mahler HIM, Kulik JA. Optimism, pessimism and recovery from coronary bypass surgery: prediction of affect, pain and functional status. Psychol Heal Med.2000;5:347–58.
[39] Juergens MC, Seekatz B, Moosdorf RG, Petrie KJ, Rief W. Illness beliefs before cardiac surgery predict disability, quality of life, and depression 3 months later. J Psychosom Res. 2010;68:553–60.
[40] Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40:87–165 This article summarizes the current guidelines on myocardial revascularization without adequately considering the importance of preoperative psychosocial risk factors for outcomes after cardiac surgery.
[41] Van Middendorp H, Lumley MA, Jacobs JWG, Bijlsma JWJ, Geenen R. The effects of anger and sadness on clinical pain reports and experimentally-induced pain thresholds in women with and without fibromyalgia. Arthritis Care Res.2010;62:1370–6.
[42] Kutty VR, Balakrishnan KG, Jayasree AK, Thomas J. Prevalence of coronary heart disease in the rural population of Thiruvananthapuram district, Kerala, India. International journal of cardiology. 1993 Apr 30;39(1):59-70.
[43] Pocock SJ, Henderson RA, Rickards AF, Hampton JR, King S3, Hamm CW, Puel J, Hueb W, Goy JJ, Rodriguez A. Meta-analysis of randomised trials comparing coronary angioplasty with bypass surgery. The Lancet. 1995 Nov 4;346(8984):1184-9.
[44] Nicholson A, Kuper H, Hemingway H. Depression as an aetiologic and prognostic factor in coronary heart disease: a meta-analysis of 6362 events among 146 538 participants in 54 observational studies. European Heart Journal. 2006 Dec 1;27(23):2763-74.
[45] Serruys PW, Luijten HE, Beatt KJ, Geuskens R, De Feyter PJ, van den Brand MJ, Reiber JH, Ten Katen HJ, van Es GA, Hugenholtz PG. Incidence of restenosis after successful coronary angioplasty: a time-related phenomenon. A quantitative angiographic study in 342 consecutive patients at 1, 2, 3, and 4 months. Circulation. 1988 Feb 1;77(2):361-71.
[46] Morse S.S. The prevalence of CAD among adults in the USA. World Health Organization report [serial online] 2008 Jan-Mar [cited 2009 Jun 5];1(1):[24 screens]. Available from: URL: http://www.cdc.gov/ncidod/EID /eid.htm.
[47] Post Coronary Artery Bypass Graft Trial Investigators. The effect of aggressive lowering of low-density lipoprotein cholesterol levels and low-dose anticoagulation on obstructive changes in saphenous-vein coronary-artery bypass grafts. N Engl J Med. 1997 Jan 16;1997(336):153-63.
[48] Krannich JH, Weyers P, Lueger S, Herzog M, Bohrer T, Elert O. Presence of depression and anxiety before and after coronary artery bypass graft surgery and their relationship to age. BMC psychiatry. 2007 Sep 12;7(1):47.
[49] Kok L, Sep M, Veldhuijzen D, Cornelisse S, Nierich A, Van der Maaten J, Rosseel P, Hofland J, Dieleman J, Vinkers C, Peelen L. Trait anxiety mediates stress-related psychopathology after cardiac surgery and ICU stay. Critical Care. 2015 Mar 16;19(1):1.
[50] Jens H, Krannich A, Presence of depression and anxiety before and after CABG surgery and their relationship to age, (serial online), 2006 Jan-February (cited 2007 march 9)5(5):[24 screens], available from: URL: http://www.Biomed central.com/cpisum
[51] Philip J, Robert B, Is preoperative anxiety and depression associated with onset of delirium after cardiac surgery in older patients? A prospective cohort study, (serial online) 2002 April-May (cited 2012 june 9);1(1):[24 screens] Available from: URL: http://www.isisi cor.com/cpisum.
[52] Edell G.A, Gustafsson M.K and Hetter A, Psychological wellbeing following cardiac surgery, (serial online) 2002 June-July (cited 2010june 9);3(3)[19 screens], Available from: URL: http://www.isisi cor.com/cpisum
[53] Chaudhary. S, Sharma. S, Psychological correlates of outcome after Coronary Artery Bypass Graft, (serial online) 2002 April-May(cited 2006june 9);2(2):[23 screens], Available from: url: http://www.isisi cor.com/htm
[54] Schelling G, Richter M, Roozendaal B, Rothenhäusler HB, Krauseneck T, Stoll C, Nollert G, Schmidt M, Kapfhammer HP. Exposure to high stress in the intensive care unit may have negative effects on health-related quality-of-life outcomes after cardiac surgery. Critical care medicine. 2003 Jul 1;31(7):1971-80.
[55] Robert A.J. ‘Mood state as a predictor of neuropsychological deficits following cardiac surgery, (serial online) 2005 April-May (cited 2006, June 9)2(2):[21 screens], Available from: url: http://www.isisi cor.com/htm
[56] Grossi GN‘Anxiety level of the patient before CABG’ (serial online) 2010 July-Auguest (cited 2010, April 5)2(2):[21 screens], Available from: url: http://www.isisi cor.com/htm
[57] Veldhurjen. D, ‘Trait anxiety mediates stress related psychopathology after cardiac surgery’ (serial online) 2002 April-May (cited 2003, June 9)2(2):[21 screens], Available from: url: http://www.isisi cor.com/htm
[58] Badner, N.H., Nielson, W.R., Munk, S. et al. Preoperative anxiety: detection and contributing factors. Can J Anaesth 37, 444–447 (1990).
[59] Norris W, Baird WLM. Preoperative anxiety - a study of the incidence and aetiology. Br J Anaesth 1967; 39: 503-9. 2 Johnson M. Anxiety in surgical patients. Psychol Med 1980; I0: 145-52.
[60] Guo P, East L, Arthur A. A preoperative education intervention to reduce anxiety and improve recovery among Chinese cardiac patients: a randomized controlled trial. International journal of nursing studies. 2012 Feb 29;49(2):129-37
[61] Asilioglu K, Celik SS. The effect of preoperative education on anxiety of open cardiac surgery patients. Patient education and counseling. 2004 Apr 30;53(1):65-70.
[62] Detroyer E, Dobbels F, Verfaillie E, Meyfroidt G, Sergeant P, Milisen K. Is preoperative anxiety and depression associated with onset of delirium after cardiac surgery in older patients? A prospective cohort study. Journal of the American Geriatrics Society. 2008 Dec 1;56(12):2278-84.
[63] Ramesh C, Nayak BS, Pai VB, Patil NT, George A, George LS, et al. Effect of preoperative education on postoperative outcomes among patients undergoing cardiac surgery: a systematic review and meta-analysis. J Peri Anesthesia Nurs. 2017.
[64] Ronaldson A, Poole L, Kidd T, Leigh E, Jahangiri M, Steptoe A. Optimism measured pre-operatively is associated with reduced pain intensity and physical symptom reporting after coronary artery bypass graft surgery. J Psychosom Res. 2014;77:278–82.
[65] Scheier MF, Matthews KA, Owens JF, Schulz R, Bridges MW, Magovern GJ, et al. Optimism and rehospitalization after coronary artery bypass graft surgery. Arch Intern Med. 1999;159:829–35.
[66] Barefoot JC, Brummett BH, Williams RB, Siegler IC, Helms MJ, Boyle SH, et al. Recovery expectations and long-term prognosis of patients with coronary heart disease. Arch Intern Med. 2011;171: 929–35.
[67] Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361 70.
[68] Bening, C., Weiler, H., Vahl, C.-F., 2013. Effects of gender, ejection fraction and weight on cardiac force development in patients undergoing cardiac surgery – an experimental examination. J. Cardiothorac. Surg. 8, 214.
[69] Bouchoucha, M., Hejnar, M., Devroede, G., Babba, T., Bon, C., Benamouzig, R., 2013. Anxiety and depression as markers of multiplicity of sites of functional gastrointestinal disorders: a gender issue? Clin. Res Hepatol. Gastroenterol. 37, 422–430.
[70] M Yıldız T, Malak A, Göktaş SB, Özen Y. Effect of Patient Education on Patient Anxiety Level Using “Scale of Patient Education Requirements” in Open Heart Surgery. Kosuyolu Heart Journal. 2015;18(1):1-5.
[71] Sharif F, Shoul A, Janati M, Kojuri J, Zare N. The effect of cardiac rehabilitation on anxiety and depression in patients undergoing cardiac bypass graft surgery in Iran. BMC cardiovascular disorders. 2012 Jun 8;12(1):1.
[72] Joseph G. Efficacy of certain structured pre operative instructional materials in improving the level of compliance during post operative period among patients undergoing cardiothoracic surgery (serial online) 2002 April-May (cited 2010 june 9);3(3) [19 screens], Available from: URL: http://www.isisi cor.com/cpisum