Understanding How to Improve Cardiac Rehabilitation for Women

Teresa Caulin-Glaser, M.D.

Teresa Caulin-Glaser, M.D., Associate Professor of Internal Medicine (Cardiology)

Cardiovascular disease is the leading cause of death among women in the United States, and has claimed the lives of more women than men in every year since 1984. Increasing evidence suggests that psychological factors influence recovery from heart attack, yet psychological symptoms are frequently unrecognized and untreated, particularly in older women with heart disease. Dr. Caulin-Glaser studied the use of complementary medicine techniques added to traditional cardiac rehabilitation to enhance psychological determinants of positive outcome after heart attack, angioplasty or coronary bypass surgery.

Highlighted Study Findings

Recent studies have demonstrated that depression and stress may aid in the development of heart disease by contributing to inflammation of coronary arteries. Traditional cardiac rehabilitation programs are recommended as part of therapy after cardiac events in order to control cardiac symptoms, decrease the risk of another heart attack and death, and prevent progression of the disease.  It has been shown that women respond less well to traditional rehabilitation. In this investigation, Dr. Caulin-Glaser studied a complementary medicine technique known as guided imagery, added to traditional cardiac rehabilitation, for women who have had a heart attack, angioplasty or coronary bypass surgery. Guided imagery is a process of creating a mental image to help a patient achieve a state of relaxation. The results demonstrated that women are significantly more depressed after a cardiac event compared to men, and the addition of guided imagery to cardiac rehabilitation was associated with a greater improvement in depressive symptoms compared to cardiac rehabilitation alone, especially in women. Finally, the addition of guided imagery to traditional cardiac rehabilitation was associated with a significant decrease in markers of inflammation affecting arteries. This research advanced understanding of the importance of assessing multiple risk factors for cardiac disease, including psychological symptoms such as depression, and demonstrated promise for novel techniques related to complementary medicine to improve cardiac rehabilitation programs for women and improve outcomes for women after heart attack.

Pilot Project Study was funded in 2001, Dr. Caulin-Glaser is now at the McConnell Heart Health Center, OH

Using Light Therapy for Depression During Pregnancy

C. Neill Epperson

C. Neill Epperson, M.D., Associate Professor of Psychiatry
(Collaborator: Dan A. Oren, M.D.)

For two decades, scientists have known that bright light therapy can be an effective treatment for seasonal depression. Various scientific and historical reasons led pregnant women with depression to be excluded from studies assessing the effects of drugs and devices on depression. As a result, the value of a benign and efficacious physiological antidepressant treatment remains unknown in a population that might benefit from it especially. Dr. Epperson’s study investigated whether bright light therapy regardless of the season can have antidepressant effects in pregnant women who chose not to take antidepressant medication due to possible iatrogenic effects of such medication on their pregnancies.

Highlighted Study Findings

Women with depression during pregnancy showed symptom improvement with light therapy, and increased depressive symptoms after light therapy was halted. Melatonin, a hormone that affects mood, is altered in depression. This alteration of melatonin functioning was corrected with successful light therapy treatment, advancing the notion that depression during pregnancy can be alleviated by light therapy treatment. This response is similar to that seen in individuals undergoing light treatment for seasonal depression. These findings suggest that bright light therapy has antidepressant effects in depressed pregnant women, regardless of the season. This study provides support for the use of light therapy as a safe, effective treatment of depression in pregnant women, without the use of medication.

Gender Differences in the Prevalence of Undiagnosed Diabetes in Acute Coronary Syndromes: Understanding the relationship of cardiac and metabolic risk factors

Barbara Gulanski, M.D., Associate Professor of Internal Medicine (Endocrinology)

Women with diabetes are at particularly high risk for severe heart disease. Dr. Gulanski’s study represented an initial step to uncover the underlying reasons for this association by examining such factors as the role of inflammation of the vascular system and subsequent atherosclerosis (hardening of the arteries).

Highlighted Study Findings

Dr. Gulanski’s Ethel F. Donaghue Women’s Health Investigator Program-funded study screened more than 1,000 patients with an admitting diagnosis of acute coronary syndrome (ACS), with the goal of identifying the prevalence of impaired glucose tolerance/undiagnosed diabetes. The investigation found that women appeared to have a higher prevalence of glucose intolerance than men. Moreover, it appeared that younger women were more likely to have diabetes and resulting heart disease. From a practical health-benefit standpoint, the study showed it was important to treat the diabetes of young women aggressively to prevent further complications. The results also demonstrated the need for aggressive screening for diabetes in the primary care setting and screening for undiagnosed diabetes among ACS patients, especially young women.

Determining the Clinical Presentation of Coronary Ischemia in Women

Viola Vaccarino, M.D., Ph.D., Associate Professor of Epidemiology and Public Health

Cardiovascular disease is the leading cause of death in both women and men. However, women who suffer a heart attack tend to have less typical signs and symptoms, and are less likely to receive recommended treatments compared to men. Dr. Vaccarino investigated the relationship between signs and symptoms, process of care, and outcome of acute coronary ischemia in women.  The clarification of gender differences in regard to these variables helped set a course for physicians to recognize and treat heart disease in women more promptly with the goal of improved outcomes.

Highlighted Study Findings

In this study, Dr. Vaccarino investigated the relationship between presentation characteristics, process of care, and outcome of acute coronary ischemia in women, using a large population-based cohort of female and male heart attack patients from the Worcester Heart Attack Study. The results showed that only 54% of women hospitalized with a heart attack presented with a chief complaint of chest pain, compared with 69% of men. Although women tended to present less often with a chief complaint of chest pain in all age groups, this gender difference was most marked in older patients. The second most common chief complaint was respiratory (breathing) problems, and younger women were twice as likely to present with respiratory symptoms as their chief complaint than were men of the same age. Despite their relative lack of traditional diagnostic indicators of heart attack, women have more severe clinical abnormalities and higher mortality than do men. Because of less typical presentations, women may delay longer in reaching the hospital, and health care providers may delay appropriate treatments - leading to higher mortality in women. Less typical presentations may also lead to delayed identification of coronary disease in women, with women being diagnosed and treated at more advanced stages of the disease compared with men. Overall, a large number of both women and men who were ultimately diagnosed as having a heart attack did not present with chest pain as their chief complaint. The clarification of gender differences in clinical presentation of acute coronary ischemia will help physicians recognize and treat heart disease in women more promptly, resulting in improved outcomes.

Pilot Project Study was funded in 2000, Dr. Vaccarino is now at Emory University, GA

Determining if Gender Affects Recovery After Bypass Surgery

Viola Vaccarino, M.D., Ph.D., Associate Professor of Epidemiology and Public Health

More than 80,000 women undergo coronary artery bypass surgery in the United States each year. However, possible gender differences in the risks and benefits of a coronary artery bypass are not well known. In this investigation, the first study to target gender differences in bypass recovery, Dr. Vaccarino found that women experience significantly worse outcomes than men and are almost twice as likely to require re-hospitalization. Prior to this investigation, women who underwent heart bypass surgery were provided recovery data obtained from studies either exclusively on men, or from studies in which few women were included and data were pooled into a single group.

Highlighted Study Findings

Gender differences in the risks and benefits of a coronary artery bypass graft were previously unknown. This study explored differences in recovery from heart bypass surgery in 1,000 women and men. The study showed that women fared significantly worse than men following heart bypass surgery. When compared to the men, the women experienced more difficult recovery after leaving the hospital. At two months and then when followed up at six months, women reported more physical problems, lower levels of physical functioning and more depressive symptoms, and were almost twice as likely as men to be readmitted to the hospital. These findings were the first to show these gender differences, thus providing the necessary groundwork for studying why these differences exist and the importance of developing gender-specific interventions that can improve the health of women after heart bypass surgery.

Pilot Project Study was funded in 1998, Dr. Vaccarino is now at Emory University, GA