Präoperative Erwartungsoptimierung und deren psychoneuroimmunologische Effekte bei herzchirurgischen Patienten

Die Koronare Herzkrankheit (KHK) ist eine der weltweit führenden Ursachen für Morbidität, krankheitsbedingte Beeinträchtigung, Erwerbsunfähigkeit und Mortalität (Go et al., 2014; Halaris, 2013; Murray & Lopez, 2013; Naghavi et al., 2015). Die aortokoronare Bypass-Operation hat sich als Goldstand...

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Bibliographic Details
Main Author: Salzmann, Stefan
Contributors: Rief, Winfried (Prof. Dr.) (Thesis advisor)
Format: Doctoral Thesis
Published: Philipps-Universität Marburg 2017
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Coronary heart disease (CHD) is one of the world’s leading causes for morbidity, disability, inability to work and mortality (Go et al., 2014; Halaris, 2013; Murray & Lopez, 2013; Naghavi et al., 2015). Coronary artery bypass graft (CABG) surgery has become the gold standard for the treatment of severe cases of CHD (Cohen et al., 2011). A significant amount of patients undergoing CABG surgery to treat coronary artery disease does not benefit to the extent surgeons would predict from a medical perspective (Hawkes et al., 2006). Patients’ disability and health-related quality of life can remain unsatisfactory, although heart functioning has been restored successfully (Hawkes et al., 2006). Patients’ expectations contribute substantially to treatment effects in CABG surgery (Auer et al., 2016; Juergens et al., 2010). Optimizing expectations may thus have the potential to optimize postoperative outcomes. Therefore, the PSY-HEART trial (PSY-chological intervention in HEART surgery patients) was conducted. This study aimed to examine, whether optimized expectations in CABG surgery patients would be able to improve postoperative long-term outcomes. In a prospective three-arm randomized controlled trial with a six months follow-up, 124 patients scheduled to undergo CABG surgery were randomized to either a brief psychological intervention to optimize patients’ expectations (EXPECT), a brief supportive preoperative psychological intervention (SUPPORT) or standard medical care (SMC) only. Studies 1-3 in this dissertation are part of the PSY-HEART trial. The goal of study 1 was to develop and describe a brief preoperative psychological intervention to optimize expectations of patients undergoing CABG surgery. In study 1 we were able to show that this intervention was well accepted by the patients and is feasible during everyday routine in a cardiac surgery setting. Since stress is associated with disease development (Chrousos, 2009; Nater et al., 2013), influenced by expectations (Goldstein, 2010; Lazarus & Folkman, 1987; Ursin & Eriksen, 2010) and may explain the association between expectations and treatment outcomes, study 2 & 3 were aiming to examine the effects of the expectation optimizing intervention on postoperative physiological stress (study 2) and pro-inflammatory parameters (study 3). Results of study 2 indicated, that both of the preoperative psychological interventions were able to buffer postoperative adrenaline levels compared to the SMC group, while lower postoperative adrenaline levels were associated with lower disability levels six months after surgery. In study 3 we were able to show that both preoperative psychological interventions led to lower postoperative interleukin-8 increases compared to SMC only, and a specific intervention effect for the expectation optimizing intervention in terms of lower interleukin-6 levels six months after surgery compared to SMC only. Study 4 was conducted to deepen the findings of the studies 1-3 and to examine whether a psychological intervention to specifically increase personal control expec-tations prior to stress compared to a gratitude and a distraction intervention would lead to a lower subjective and physiological stress response after an acute stressor in an experimental design in a healthy sample. The expectation optimizing intervention and the distraction intervention led to significant lower cortisol levels after stress compared to the gratitude intervention. Personality traits moderated intervention effects. As a part of the PSY-HEART trial this dissertation was able to show, that a brief pre-operative psychological intervention to optimize expectations in patients before un-dergoing CABG surgery is capable of positively influencing the postoperative stress response and that this has positive effects on long-term surgery outcomes. In an ex-perimental design it was shown that a brief psychological intervention prior to stress is able to alter the physiological stress response after a stressor. These findings also underline the relevance of preoperative expectations in medical settings in general and suggest the implementation of a similar intervention into standard medical care.