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Acute coronary syndrome, brief supportive psychotherapy, neutrophil-lymphocyte ratio, psychological symptoms.
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Shatri H, Ismail RI, Putranto R et al. A randomized control clinical trial of brief supportive psychotherapy in acute coronary syndrome patients: focus on neutrophil-lymphocyte ratio and psychological symptoms [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:72 (https://doi.org/10.12688/f1000research.140476.1)
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Research Article
Clinical trial
A randomized control clinical trial of brief supportive psychotherapy in acute coronary syndrome patients: focus on neutrophil-lymphocyte ratio and psychological symptoms
[version 1; peer review: awaiting peer review]
PUBLISHED 16 Jan 2024
OPEN PEER REVIEW
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Abstract
Corresponding author:
Vera Abdullah
Competing interests:
No competing interests were disclosed.
Grant information:
This study was supported by Universitas Indonesia (NKB-0399/UN2.R3.1/HKP.05.00/2019).
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Copyright:
© 2024 Shatri H et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Shatri H, Ismail RI, Putranto R et al. A randomized control clinical trial of brief supportive psychotherapy in acute coronary syndrome patients: focus on neutrophil-lymphocyte ratio and psychological symptoms [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:72 (https://doi.org/10.12688/f1000research.140476.1)
First published: 16 Jan 2024, 13:72 (https://doi.org/10.12688/f1000research.140476.1)
Latest published: 16 Jan 2024, 13:72 (https://doi.org/10.12688/f1000research.140476.1)
The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Introduction
Acute coronary syndrome (ACS), an acute clinical syndrome of myocardial ischemic or infarction and coronary arterial disease are estimated globally to reach 7 million deaths annually. The mortality rate associated ACS remained relatively high by nearly 5% during hospitalization and reached twice a year after hospitalization in Asia-Pacific region.1 Our internal data in ICCU RSCM showed 31 (7.18%) patients died during hospitalization. Hence, a comprehensive approach which involving physical and psychological efforts is needed to continue reducing the incidence.
Psychological distress of patients with myocardial infarction happened from the interaction of many factors operating before, during, and after the occurrence of infarction, such as age, duration of illness, personality, and emotional reaction, the family, friends, and work environment as well as the physicians. Psychotherapy as a non-pharmacological approach should become an integrative intervention as part of the rehabilitation of patients with coronary heart disease (CHD), especially for those who are difficult to accept the disease. European CVD prevention guidelines in clinical practice 2016 recommended behavioral interventions of various modalities as first class recommendations.2–4 There are various types of psychotherapy that have been developed based on patient’s condition.5 Brief supportive psychotherapy focuses on building confidence, reducing anxiety, and improving coping mechanisms which is usually less than 8 or 20 sessions and can be performed every day or each week or month.6 Some studies showed patients with ACS got an improvement of psychosocial adaption7; reduction of supraventricular arrhythmias, congestive heart disease, weakness, depression, affective social, anxiety, and fear8; and cardiac symptoms improvement, quality of life, and reduction of rehospitalization.2
Supportive psychotherapy should be given based on the patient’s goals, socio-cultural and clinical backgrounds. Neutrophil-lymphocyte ratio is a cardiac marker which is relatively cheap and can predict the prognosis of patients with ACS.9–11 Hence, it was needed to know the effect of continuous psychotherapy in ACS patients who were hospitalized in ICCU with limited physical and psychological conditions in early phase on NLR and psychological symptoms.
Methods
This study was an open clinical randomized controlled which was done in Intensive Cardiac Care Unit Cipto Mangunkusumo Hospital in April to May 2019. Patients admitted from the emergency room or other unit who were clinically stable (the first day in ICCU and their condition was capable to be join in study), could be accepted as the research subjects. The sample size was calculated before, it was about 36 patients each group, included the drop out about 10%. They were selected consecutively and allocated randomly by block permuted in receiving brief supportive psychotherapy or only receiving standard treatment (the treatment for ACS patients, such as dual antiplatelet agents, anticoagulant drugs, vasodilator agents, dyslipidemia agents, etc.). Patients who were diagnosed with ACS, aged of ≥18 years, and had standard pharmacological treatment either had PCI or not were eligible for this study. Patients who had stroke, cardiogenic shock at hospital admission, and psychosis were excluded. All patients independently signed informed consent forms. This study has been approved by Ethics Committee of Faculty of Medicine University of Indonesia (No: KET-177/UN2.F1/ETIK/PPM.00.02/2019). This trial had registered in ClinicalTrial.gov.id with code number NCT04274205.
Interventions
Brief supportive psychotherapy (BSP) was done by one internist from Psychosomatic Division. There was only a single psychotherapist for all patients. The communication between psychotherapist and patients used the guidance of BSP in acute coronary syndrome which had allowed of the experts of psychology. It consists of communication steps i.e. the self-introduction, ask about symptoms, feeling and worries, support for decision making, evaluation and summary. In classification of psychotherapy, BSP is a supportive psychotherapy, and based on the depth of intervention, it is classified as superficial psychotherapy.12 The process consists of ventilation, supportive and education. It took time about 30 minutes in one session. The technical procedure in this BSP i.e. first; the therapist should identify the patient (name, gender, age), it could be found in medical record, second; ask about patient’s name and birth date, third; explain about the intention and meaning of meeting, fourth; offer to the patient what the therapist could help with, fifth; ask the patient to describe about his/her feeling today, sixth; the therapist decides patient’s ability of ego function, seventh; the therapist confirms the patient has ability to face the problem or disease, eighth; the therapist supports the patient in facing this problem or the later, ninth; the therapist gives comprehension and education in case of physically and psychologically problem, tenth; ask if other thing that make uncomfortable or still unclear to patient and the last; ask permission to end the meeting.
Data analysis
Clinical and laboratory data were collected from medical records. Anxiety and depression were assessed using hospital anxiety depression scale (HADS) Indonesian version13–15 which had been assessed reliability by M Rudi et al14 that showed Kappa coefficient 0.706 (p<0.01) for anxiety and 0.681 (p<0.01) for depression. Complete peripheral blood examination was done after the whole session of BSP or before discharge. Baseline data were retrieved at ICCU admission.
Data on age, gender, ACS type, comorbidities, number of coronary artery stenosis, ejection fraction (EF), creatine kinase of myocardial band (CK-MB), random blood glucose (RBG), high density lipoprotein (HDL), low density lipoprotein (LDL), leukocytes, differential count of leukocytes, neutrophil-lymphocyte ratio, length of stay in ICCU were collected.
Data analysis used SPSS 22 for Windows program. Categorical variables were presented as frequencies and percentages while numerical variables as means and standard deviation if they were normally distributed while medians and range as alternative. Chi-square test or Fisher’s exact test was used for assessing association of categorical data between two groups. Independent T-test or Mann-Whitney test was used to compare means and medians between two groups. P value<0.05 was considered significant.
Results
There were 130 patients who were admitted to ICCU during that period, but there were only 72 patients who were randomized. There were incomplete data in 5 subjects, thus only 67 subjects were analyzed in this study (Figure 1). The 58-excluded subjects were due to unstable patients with shock, unconsciousness or ventilator needed.
Figure 1. Analysis pathway of research subjects.
Subjects’ characteristics are shown in Table 1. We found that most of the subjects were men, which STEMI dominantly as ACS type while dyslipidemia as the most comorbidity followed by hypertension.
Table 1. Baseline characteristics of research subjects.
NLR, anxiety score, depression score, and HADS score after 5-intervention days were similar in two groups (Table 2). BSP reduced NLR higher than control, but the change was not significant. There were similar changes of anxiety score in both groups. Meanwhile, depression score and total HADS score improved better in patients receiving BSP.
Table 2. NLR and psychological symptoms (HADS) in BSP and control group.
| Clinical variables | BSP N=32 | Control N=35 | p | 95% CI |
|---|---|---|---|---|
| Post-intervention NLR, mean (SD) | 3.35 (2.26) | 3.63 (1.79) | 0.346* | -1.27 – 0.71 |
| Δ NLR, mean (SD) | 2.92 (4.85) | 1.43 (4.09) | 0.098 | -0.69 – 3.67 |
| Post-intervention anxiety score, mean (SD) | 4.63 (3.52) | 4.31 (2.62) | 0.874* | -1.19 – 1.82 |
| Δ Anxiety score, mean (SD) | 0.19 (4.16) | 0.2 (2.63) | 0.988 | -1.74 – 1.71 |
| Post-intervention depression score, mean (SD) | 4.91 (2.63) | 4.37 (3.05) | 0.447# | -0.86 – 1.93 |
| Δ Depression score, mean (SD) | 0.87 (3.97) | -0.74 (3.36) | 0.149 | -0.17 – 3.41 |
| Post-intervention HADS, mean (SD) | 9.53 (5.02) | 8.69 (4.51) | 0.470# | -1.48 – 3.17 |
| Δ HADS score, mean (SD) | 1.06 (6.49) | -0.54 (4.55) | 0.242 | -1.11 – 4.32 |
Table 3 shows subgroup analysis of the effect of BSP on NLR and psychological symptoms in ACS patients between comorbidities. In patients without CHF or CAD, reduction of NLR were higher in control than BSP. It also influenced on psychological symptoms (depression) change in ACS patients with CHF or CAD.
Table 3. Subgroup analysis of NLR and psychological symptoms (anxiety or depression) changes in subjects with and without comorbidities.
| Comorbidities | BSP N=32 | Control N=35 | P value | 95% CI | Effect size | 95% CI |
|---|---|---|---|---|---|---|
| Chronic heart failure | ||||||
| Δ NLR, mean (SD)# | 1.09 (2.68) | 3.83 (5.73) | 0.116 | -6.72–1.24 | -0.34 | |
| Δ anxiety score, mean (SD)# | 0.27 (3.66) | 0.27 (2.28) | 0.949 | -2.71–2.71 | -0.02 | |
| Δ depression score, mean (SD) | 1.73 (3.58) | -1.27 (2.8) | 0.041* | 0.13–5.87 | 0.86** | 0.04–1.68 |
| Δ NLR, mean (SD) | 3.87 (5.48) | 0.33 (2.54) | 0.007* | 1.03–6.06 | 0.79** | 0.23–1.35 |
| Δ anxiety score, mean (SD) | 0.14 (4.49) | 0.17 (2.82) | 0.983 | -2.33–2.28 | -0.006 | -0.64–0.62 |
| Δ depression score, mean (SD) | 0.43 (4.17) | -0.5 (3.62) | 0.429 | -1.41–3.27 | 0.24** | -0.36–0.84 |
| Coronary arterial disease | ||||||
| Δ NLR, mean (SD)# | 1.31 (5.08) | 2.04 (5.56) | 0.867 | -5.15–3.37 | -0.037 | |
| Δ anxiety score, mean (SD) | -0.42 (4.32) | -0.07 (2.46) | 0.793 | -3.06–2.36 | -0.105 | -0.91–0.70 |
| Δ depression score, mean (SD) | 2.08 (3.4) | -0.8 (3.3) | 0.035* | 0.22–5.54 | 0.80** | 0.06–1.54 |
| Δ NLR, mean (SD)# | 3.88 (4.55) | 0.84 (2.51) | 0.014* | 0.68–5.40 | 0.77$ | 0.17–1.37 |
| Δ anxiety score, mean (SD) | 0.55 (4.14) | 0.4 (2.8) | 0.894 | -2.11–2.41 | 0.04 | -0.61–0.69 |
| Δ depression score, mean (SD) | 0.15 (4.2) | -0.7 (3.5) | 0.491 | -1.62–3.32 | 0.22** | -0.42–0.86 |
Discussion
This study showed that BSP approximately 30–45 minutes daily, 5 consecutive days in patients having ACS can decrease NLR, but the reduction was only significant in patients without previous CAD or CHF. BSP can lower NLR which it is as an acute inflammation marker in ACS patients. This condition may be resulted from psycho-neuroendocrinology and immunology mechanisms. Thamhane et al.2 showed higher neutrophil absolute count associated with worse angiography results, larger infarction size, and worse short-term prognosis in patients with ST-elevation myocardial infarct (STEMI). Neutrophils play role in mediating inflammation response in acute injury by various cellular mechanism that yields advance tissue damage. Meanwhile, lymphopenia is resulted from stress response that is mediated by endogen cortisol increase and as an early marker in acute myocardial infarction. Higher NLR may act as an independent predictor for lower survival after hospital discharge and mortality risk/MACE.2,16 Hence, BSP may have role in immune system through hypothalamic-pituitary-adrenal axis.17
Anxiety was prevalent at baseline. It trended toward decrease in borderline criteria proportion of them, but dominantly in BSP one. It decreased in abnormal criteria proportion of them in BSP group, but no patient in control one who fulfilled more than 10 in HADS. It could be happened because anxiety is hard to evaluate in acute physical condition of ACS or there was role of anxiolytic drugs which they received. Most of the patients with depression and borderline depression in BSP group became normal, but it was lower in the control group. Standard cardiology treatment had also improved psychological symptoms especially for depression. BSP improved depression score in ACS patients with CHF or CAD. It may be occurred because there is role of autonomic nervous system and hypothalamic-pituitary-adrenal axis by approach of this method,17,18 moreover it could be cause of heart as immune organ.19–21 Up to date, there is no research that observes effect of BSP on NLR and psychological symptoms in ACS patients with CHF and CAD.
The limitation of this study is the BSP was done only in 5 sessions with 30 minutes each session instead of 8–20 sessions because we only did this in the ICCU. Meanwhile, this study was the first study in Indonesia to associate BSP on NLR and psychological symptoms in ACS patients. This may be a basis on further research on BSP. This clinical trial may also show that we should comprehensively care patients with ACS to improve their quality of life.
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how to cite this article
Shatri H, Ismail RI, Putranto R et al. A randomized control clinical trial of brief supportive psychotherapy in acute coronary syndrome patients: focus on neutrophil-lymphocyte ratio and psychological symptoms [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:72 (https://doi.org/10.12688/f1000research.140476.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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