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The present investigation was a descriptive and cross-sectional survey using a structured questionnaire and medical history including laboratory tests of CHD patients. The participants were recruited consecutively from a coronary follow-up clinic between August 2013 and September 2015 at their one-year follow-up after PCI. The reason for the one-year time point is because in our hospital, as in many hospitals in China, post-PCI patients are asked to return to the clinic for a comprehensive examination 1 year after the procedure. This follow-up visit is an easy way to obtain patients’ data and clinical condition. We therefore chose this time point to attain the cross-sectional information in this study. After obtaining informed consent, patients’ eligibility was confirmed by analyzing their medical records for the inclusion and exclusion criteria. Participants were included if they (1) were 18 to 70 years old; (2) had a diagnosis of coronary heart disease; (3) underwent PCI one year ago; (4) accepted participation in this study; and (5) were able to speak, read, and write Chinese. Participants were excluded if they had (1) a terminal illness, (2) abnormal renal and liver function, (3) a limb deficiency, or (4) a language comprehension disorder.
Two investigators (Feng C. and Ji T.) interviewed the patients to gather sociodemographics such as age, gender, type of PCI, education, cigarette smoking status, body mass index, hypertension history, diabetes mellitus, and self-management abilities (physical activity). Data from physical examinations [including height, weight, and systolic and diastolic blood pressure (SBP and DBP, respectively)] and biochemical testing [total cholesterol (TCHO), total triglycerides (TG), low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, fasting blood glucose (FBG), and glycated hemoglobin A1c (HbA1c) levels] were obtained from all participants. These medial data was obtained from their medical chart in our medical records system. Participants’ depression status was calculated via the 9-item Patient Health Questionnaire (PHQ-9), which was administered in a private room using structured questionnaires. The PHQ-9 consists of nine items, each of which assesses the existence of 1 of the 9 DSM-IV criteria for a depressive episode in the past two weeks. Each question in the PHQ-9 is answered using a 4-point scale ranging from 0 (never) to 3 (nearly every day), for a total score ranging from 0 to 27; higher scores indicate a higher likelihood of major depressive disorder. The PHQ-9 questionnaire is a one-page survey and can be accomplished alone. The PHQ-9 questionnaire was first translated into Chinese by a bilingual psychiatrist. The answers were reviewed by 2 independent research coordinators for accuracy.
Validation of the PHQ-9 in the Chinese sample: The translated version was back-translated and modified until the back-translated version was comparable with the original English version. Some patients were invited to review the Chinese version and to provide feedback. Some modifications were made before the final version of the PHQ-9 was completed. The reliability of the Chinese version of the PHQ-9 was tested. The internal consistency value, obtained by using Cronbach α coefficient, was 0.81 (95% CI, 0.80–0.83). To assess test-retest reliability, 265 patients completed the PHQ-9 a second time within 2 weeks. The intraclass correlation coefficient for test-retest reliability of the total scores was 0.86 (95% CI, 0.83–0.91; F = 7.73, df = 264, P<0.01), demonstrating limited variability between the two-week time points.
Measurement of physical examination and biochemical variables: After the participants had rested for 10 min, blood pressure (BP) was obtained three times with a desktop mercury column sphygmomanometer with participants in a seated position. The time interval between each measurement was 2 minutes. The average of the BP values was calculated and used for analysis. Blood samples were drawn from each patient after they had fasted for at least 12 h and rested overnight. FBG levels were obtained using oxygen electrodes; TCHO levels were measured using the cholesterol oxidase method; TG levels were measured using the enzymatic method; and HDL-C and LDL-C levels were directly measured using the clearance method. GHbA1c level was measured using high-performance liquid chromatography.
In the PHQ-9, compared with a lower score, a higher score reveals more depression. As indicated previously, a score of 10 is the ideal cutoff for detecting the presence of major depression in Chinese patients [11]. We therefore used the cutoff value of ≥10 for major depression. The goals of secondary prevention of CHD include the following: 1) complete non-smoking: never smoked or stopped smoking for at least 3 months; 2) ≥30 minutes of moderate-intensity aerobic activity per day ≥5 days per week: patients self-reported their physical activity mode and duration; 3) weight management resulting in BMI >18.5 kg/m2 and <25.0 kg/m2; 4) BP<140/90 mm Hg; 5) FBG <6.11 mmol/L in DM patients, and 6) LDL-C<2.6 mmol/L.
This investigation was approved by the ethics committee of Shanghai Changhai Hospital before subject enrollment, and it adhered to the principles of the Declaration of Helsinki (as revised in Brazil 2013). All participants in this research read and signed an informed consent.
For the statistical analyses of the data in this study, the Statistical Package for the Social Sciences (SPSS) version 22 (IBM Corp, Armonk, New York) was used. Differences between continuous variables were evaluated using t-tests, and the χ2 test was used for categorical variables. Logistic regression analyses were used to evaluate the associations between depression and secondary prevention of CHD patients after PCI by calculating adjusted odds ratios (ORs) and 95% confidence intervals (CIs). Adjusted factors included type of PCI, education, and amount of smoking (cigarettes per day). Missing data were not imputed. The significance level was set at .05. All demographic and clinical data, with the exception of age, are reported as frequencies and percentages; age is reported as the mean and standard deviation. Descriptive statistics, mean T standard deviations, or percentages were used to describe the participant profiles.
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