臺灣博碩士論文加值系統

研究背景: 過去研究已證實罹患急性冠心症會增加日後罹患焦慮症與憂鬱症之風險。然而截至目前為止，國內外均缺乏有效的社會心理介入措施來預防病人在急性冠心症發生後罹患焦慮與憂鬱症。因此本研究欲發展相關介入性措施，並檢視措施的效果及其可能的影響因素。
研究目的: 發展及評價非藥物介入措施於急性冠心症患者之應用。
研究設計:本研究為混合模式研究，結合臨床隨機實驗與單一組類實驗研究法。
資料收集及方法: 本研究資料收集分為兩階段，第一階段利用系統性文獻回顧與統合分析研究結果以發展本階段的實驗性介入措施與「急性冠心症出院診療計畫說明書」；之後再以隨機方式將研究對象分配到實驗組或控制組，並且兩組研究對象均接受醫院的常規性照護，包括住院時的衛教以及門診的追蹤照護。除此之外，實驗組研究對象將自住院開始接受一個月的實驗性社會心理措施，內容包括壓力處理、自我照顧技巧及放鬆技巧學習光碟等。兩組研究對象均自住院開始接受研究者追蹤6個月，並且在第1, 3, 6個月接受血脂檢測；第二階段則是實驗組對象另外需在第1, 3個月接受唾液皮質醇、焦慮與憂鬱程度等的測量。主要結果將瞭解兩組研究對象在血脂改變的差異、實驗組唾液皮質醇的變化；次要結果將瞭解兩組在冠心症復發、因心臟疾病再度住院、以及全死因死亡上之差異。
資料分析: 以SPSS for Windows 19.0統計軟體進行人口學特性與焦慮、憂鬱程度、血脂追蹤和唾液皮質醇變化的資料分析。
研究結果: 從隨機分派研究中發現，經由介入性措施後可有效控制血脂並改善日常壓力狀態。相反的，研究中量表的評估較無法反映現實狀況，此部分存在著文化差異，也是與其他研究不同之處。
結論: 研究結果能有助於健康專業人員瞭解急性冠心症患者罹病後的心理壓力與感受，更客觀、整體性的了解以協助解決「心理壓力」的原因，並提供個人化的照護，及提升專業人員對冠心症患者出院後的心理調適監測功能，建構新的冠心症者出院後追蹤照護模式。

Background: Our previous studies have demonstrated that acute coronary syndrome (ACS) patients are at an increased risk of anxiety and depression, and these patients should receive an intervention during the first 2 months after ACS. However, no randomised controlled trial has investigated whether a nonpharmacological intervention improves psychological and physiological variables in ACS patients.
Purpose: To evaluate the effects of a nonpharmacological intervention in ACS patients.
Design: The 6-month mixed-methods design, combining the randomised controlled trial and single-group quasi-experimental designs, provided a comprehensive understanding of the context in which nonpharmacological interventions can effectively prevent post-ACS anxiety and depression.
Data Collection and Intervention: In this study, data collection was divided into two phases. Phase Ⅰ: In this phase, a nonpharmacological intervention was developed. A novel intervention protocol was initiated based on the systematic review and meta-analysis findings. The intervention group (IG) received telephone or face-to-face interviews or both at 2, 4, and 12 weeks after hospital discharge. The usual care group (UG) received primary care from their clinicians. After the intervention, both groups were followed up for 6 months. The primary outcome was clinical data including the lipid profile. The secondary outcomes were the revascularization procedures and cardiovascular hospitalisations. Phase Ⅱ: Participants received 30-min intervention sessions, and each session was conducted once a week for 4 weeks. The content of the nonpharmacological intervention programme included health information regarding ACS, nutrition, life modification, medication adherence, and education about the role of stress in ACS. Anxiety and depression symptoms and daily stress were evaluated at baseline and at 1 month after the intervention.
Data Analysis: All quantitative data were analysed using SPSS for Windows, Version 19.0, with significance set at .05. Phase Ⅰ: An intention-to-treat principle was applied to all statistical analyses. Demographic characteristics and illness severity were expressed as means, standard deviations, and percentages. We used generalised estimating equations (GEE) to test whether there were changes in the between- and within-group effects over time for the participants’ physiological outcome levels. The Cox regression model was used to analyse the time elapsed between the primary and secondary events. Phase Ⅱ: The Wilcoxon signed-rank test was used to examine the changes in the Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) scores between baseline and posttest. GEEs were used to test whether the participants’ salivary cortisol levels changed over time between and within the groups, and used to evaluate the effect of the intervention on salivary cortisol over the day.
Results: Phase Ⅰ: Over the study period, 63 patients were randomised to receive either the nonpharmacological intervention (IG, n = 25) or usual care (control group; CG, n = 26). In both groups, low-density lipoprotein cholesterol and triglyceride levels decreased over time. Phase Ⅱ: A total of 25 (49%) patients were enrolled. After the nonpharmacological intervention, the mean BAI and BDI scores decreased compared with baseline scores (BAI: 15.18 ± 8.49 vs. 7.64 ± 9.87, P = .001; BDI: 6 ± 6.46 vs. 3.91 ± 5.51, P = .001). Changes in salivary cortisol upon waking, as revealed by GEEs, were not statistically significant. The 20–44 year age group exhibited flatter cortisol slopes, and men exhibited higher cortisol levels over the day than women (P < .05).
Conclusions: The results of the present study demonstrate that a 4-week nonpharmacological intervention programme improves various psychological and lipid-related variables. Nurses and clinical health professionals need to develop a holistic understanding of post-ACS patients, particularly men and young adult patients.

Table of Contents
中文摘要 IV
Abstract VI
1. Introduction 8
1.1 Background and Significance 8
2. Literature Review 9
2.1 Definition of Acute Coronary Syndrome 9
2.2 Overview of Life After Acute Coronary Syndrome 10
2.3 Stress and Responses 11
2.4 Emotional Distress in Post-Acute Coronary Syndrome 12
2.5 Consequences of Psychological Stress 14
2.6 Nonpharmacological Interventions for Post-Acute coronary syndrome 15
3. Aim, Hypotheses, Study Design, and Results 16
3.1 Aim Ⅰ 16
3.1.1 Hypothesis Ⅰ 16
3.1.2 Study Design 16
3.1.3 Random Assignment 16
3.1.4 Participant Recruitment 17
3.1.5 Developing a Nonpharmacological Intervention 17
3.1.5.1 Baseline Assessment 21
3.1.5.2 Demographic Data 21
3.1.5.3 Cardiovascular Functions and Monitoring Other Risk Factors 21
3.1.5.4 Follow-Up Evaluation 22
3.1.5.5 Outcome Measures 22
3.1.5.6 Data Analysis 22
3.1.5.7 Ethical Considerations 23
3.1.6 Aim Ⅰ Results 23
3.1.6.1 Patient Characteristics 23
3.1.6.2 Physiological Parameter Follow-up 24
3.1.6.3 Treatment Effect on Clinical Events 24
3.2 Aim Ⅱ 29
3.2.1 Hypothesis Ⅱ 29
3.2.2 Study Design, Setting, and Procedures 29
3.2.3 Participants 31
3.2.4 Data collection tools 31
3.2.4.1 Demographic Data 31
3.2.4.2 Beck Anxiety Inventory 31
3.2.4.3 Beck Depression Inventory 31
3.2.4.4 Salivary Cortisol 32
3.2.4.5 Statistical Analyses 32
3.2.5 Aim Ⅱ Results 33
3.2.5.1 Patient Characteristics 33
3.2.5.2 Effects of Intervention on Anxiety and Depression Symptoms 36
3.2.5.3 Effects of Intervention on Changes in Salivary Cortisol Upon Waking 38
3.2.5.4 Effects of Intervention on Salivary Cortisol Over the Day 38
4. Discussion 52
4.1 Study Strengths and Limitations 55
5. Conclusion 56
References 57

List of tables
Table.1. Demographic Characteristics…………………………………… 25
Table.2. Lipid Levels for two groups at the baseline and Follow-Up 26
Table.3.Comparison of Between-Group Differences in Lipid Levels at the 6-Month Follow-Up by GEE Method’s Multiple Linear Regression. 27
Table.4. Intervention Effect on Primary and Secondary Clinical Events for All Participants 28
Table.5. Medication and Baseline Characteristics of Patients (N = 25) 35
Table.6. Evaluation Results of BAI and BDI Scores Before and After the Intervention Programme 37
Table.7. Mean salivary cortisol concentrations (μg/dL) before and after the intervention program in different groups. 39
Table.8. Results of the GEE model in salivary cortisol concentrations (μg/dL) before and after the intervention program in different age groups. 40
Table.9. Results of the GEE model in salivary cortisol concentrations (μg/dL) before and after the intervention program in different sex groups. 41
Table.10. Results of the GEE model in salivary cortisol concentrations (μg/dL) before and after the intervention program in different BAI scale groups. 42
Table.11. Results of the GEE model in salivary cortisol concentrations (μg/dL) before and after the intervention program in different PSY OPD groups. 43
Table.12. Results of the GEE model in salivary cortisol concentrations (μg/dL) before and after the intervention program in different Anti-anxiety groups. 44
Table.13. Mean salivary cortisol across the three sample points of the day in ACS patients with different groups 45
Table.14. Results of the GEE model in salivary cortisol across the three sample points of the day (μg/dL) in different age groups. 46
Table.15. Results of the GEE model in salivary cortisol across the three sample points of the day (μg/dL) in different sex groups. 47
Table.16. Results of the GEE model in salivary cortisol across the three sample points of the day (μg/dL) in different BAI scale groups. 48
Table.17. Results of the GEE model in salivary cortisol across the three sample points of the day (μg/dL) in different PSY OPD groups. 49
Table.18. Results of the GEE model in salivary cortisol across the three sample points of the day (μg/dL) in different Anti-anxiety groups. 50

List of figures
Fig.1. Aim Ⅰ study framework 19
Fig.2. Flowchart of patient recruitment. 20
Fig.3. Aim Ⅱ study framework. 30
Fig.4. Flowchart of patient recruitment. 34
Fig.5. Mean salivary cortisol across the three sampling points of the day in different age groups of ACS patients 51

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