Clinical Investigations Association Between Fibromyalgia and Coronary Heart Disease and Coronary Catheterization
Address for correspondence: Jacob N. Ablin, MD Department of Internal Medicine 6 Tel-Aviv Sourasky Medical Center 6 Weizman Street Tel-Aviv 64239, Isreal
[email protected]
Jacob N. Ablin, MD, Natella Beilinson, MD,∗ Valerie Aloush, MD,∗ Ori Elkayam, MD,∗ Ariel Finkelstein, MD† ∗
Department of Internal Medicine 6; † Cardiology Institute, Tel-Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
Background: Fibromyalgia (FM) has been associated with physical and emotional trauma including invasive medical procedures. Both FM and ischemic heart disease have been linked with depression. The purpose of this study was to retrospectively investigate the frequency of FM symptoms and physical findings among patients undergoing coronary catheterization. Methods: Consecutive patients who underwent coronary angiography during the previous 6 mo were recruited. Patients with major depression, bi-polar disorder, schizophrenia, or malignancy were excluded. Patients underwent dolorimetry for tender-point assessment and completed the fibromyalgia impact questionnaire (FIQ). Group A included patients with significant coronary pathology (n = 43), group B included patients with normal coronary arteries (n = 50), and group C included patients with normal controls (n = 51). A cardiological score incorporated the number of coronary arteries with significant pathology and left ventricular function. Chi-square or Fisher’s exact test was used for categorical data and a one-way analysis of variance for continuous variables; a multivariate linear regression was performed to compare groups. Results: Significantly increased levels of tenderness were discovered among patients with coronary pathology compared with healthy controls. Significantly increased levels of depression were also found, as well as higher scores on the FIQ scale. On multivariate analysis, a positive correlation was demonstrated between tenderness/FIQ scores and a composite cardiological score. Conclusion: Coronary angiography is associated with a significantly increased frequency of pain, tenderness, and depression after 6 mo, apparent in both patients undergoing coronary procedures and patients with normal coronaries. This association may impact the outcome of patients with significant coronary disease. Key words: fibromyalgia, coronary angiography, depression Introduction Fibromyalgia (FM) is a debilitating and frustrating syndrome characterized by widespread pain and tenderness. Epidemiological studies have found the disorder to affect as many as 4.9% of the general population,1 yet its pathogenesis and treatment remain unclear.2 Fibromyalgia has been linked to the occurrence of various forms of physical trauma,3,4 infectious disorders,5,6 emotional trauma,7 and genetic factors.8 There appears to be considerable overlap between FM and depression,9 with many patients carrying both diagnoses, and medications used for the treatment of depression are frequently implemented in the management of FM.10 The correlation between coronary heart disease and depression is well documented,11,12 and claims have been made about the effect of depression on major outcomes, such as mortality in this context.13 – 15 Thus, the depression and anxiety following a myocardial infarction (MI) have been associated by some investigators with both an increased frequency of recurrent cardiac Received: August 9, 2007 Accepted with revision: September 10, 2007
events11,16 and increased mortality.13,17,18 Others, however, have failed to demonstrate depression as being a significant predictor of post-MI mortality, after adjusting for additional variables.19 The aim of the current study was to evaluate an association between FM and coronary heart disease. Specifically, we wished to compare the incidence of FM between patients who had undergone coronary angiography and were found to have normal coronary arteries with patients angiographically found to have significant coronary pathology who underwent intracoronary interventions. We aimed to establish whether there is an increased incidence of FM following these events (as had been described following other forms of physical or emotional stress) and to establish whether there is an increased incidence of FM among patients with normal coronary findings, possibly identifying a subgroup of patients who would otherwise be candidates for catheterization and for whom it is not necessary. Clin. Cardiol. 32, 6, E7–E11 (2009) Published online in Wiley InterScience. (www.interscience.wiley.com) DOI:10.1002/clc.20308 2009 Wiley Periodicals, Inc.
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Clinical Investigations
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Methods Patient Sample and Data Collection
Ninety-three consecutive patients attending the cardiology postcatheterization clinic of the Tel-Aviv Medical Center and 51 healthy controls participated in this study. Excluded were patients who reported having previously been diagnosed as suffering from major depression, bi-polar disorder, or schizophrenia as well as active malignancy. All the patients had undergone coronary catheterization within the year prior to study recruitment. They were divided into 3 groups: Group A included 43 patients with significant coronary disease at angiography, who underwent coronary angioplasty, with or without stent implantation; Group B comprised 50 patients with normal coronary arteries on angiography; and Group C included 51 age- and gendermatched apparently healthy controls with no history of coronary disease. These individuals were volunteers and included medical staff. Appropriate informed consent was obtained from all participants, and clinical research was conducted in accordance with guidelines for human experimentation specified by the Tel-Aviv Sourasky Medical Center. The study was approved by the ethics committee of the medical center. Clinical Assessment
All subjects were assessed by a single blinded observer (NB), and FM tender points were evaluated by the use of a spring-loaded dolorimeter. The force necessary to produce pain was recorded individually for each site and defined as the degree of tenderness. A force >4 kg was regarded as positive. The presence or absence of tenderness on the 18 FM tender points was determined and recorded. The patients were questioned about the presence of widespread pain, as defined in the American College of Rheumatology (ACR) criteria for FM classification.20 All the study subjects completed the 10-item fibromyalgia impact questionnaire (FIQ) regarding the effect of FM on their quality of life.21 As part of the FIQ, visual analog scales were used to evaluate current levels of pain, fatigue, morning stiffness, depression, and anxiety. The items were scored on a scale of 0–10 points, with 10 denoting the worst condition. A validated Hebrew translation22 of the original FIQ questionnaire was used, and the patient’s response to the FIQ depression scale (FIQ-D) was utilized as a measure of depression. Cardiological Score of Severity
A composite cardiological score was constructed in order to evaluate the correlation between the severity of coronary disease, and the parameters of tenderness and FIQ. This instrument incorporated the number of coronary arteries in which significant pathology was detected on angiography, as well as the estimation of left ventricular function on ventriculography.
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Clin. Cardiol. 32, 6, E7–E11 (2009) J.N. Ablin et al.: Fibromyalgia following coronary angiography Published online in Wiley InterScience. (www.interscience.wiley.com) DOI:10.1002/clc.20308 2009 Wiley Periodicals, Inc.
Ventricular function was scored as good (ejection fraction >55%), mildly impaired (ejection fraction 45%–55%), moderately impaired (ejection fraction 35%–45%), or severely impaired (ejection fraction
