ISSN : 1301-5680
e-ISSN : 2149-8156
Turkish Journal of Thoracic and Cardiovascular Surgery     
Preoperative education may attenuate anger scores of patients after cardiac surgery
İhsan Sami Uyar, Mehmet Beşir Akpınar, Veysel Şahin, Ahmet Feyzi Abacılar, Halil Uç, Rana Varol, Faik Fevzi Okur, Mehmet Ateş, Emin Alp Alayunt, Talat Tavlı
Department of Cardiovascular Surgery, Medical Faculty of Şifa University, İzmir, Turkey
DOI : 10.5606/tgkdc.dergisi.2014.9411


Background: This study aims to evaluate the anger status of patients undergoing open heart surgery and to examine possible effects of psychological support on anger control.

Methods: Anger status and type A personality were evaluated in 68 patients who underwent coronary artery bypass grafting (CABG) between September 2012 and January 2013. The patients were divided into two groups: group 1 (18 males and 16 females; mean age 55.0±8.7 year; range 43 to 78 years) received routine preoperative preparations, whereas group 2 (17 males and 17 females; mean age 54.9±9.1 years; range 41 to 81 years) received patient education for 30 minutes one day before surgery during preoperative period on anger management after heart surgery. To obtain anger scores of the patients, The State-Trait Anger Expression Inventory-2 and Scale of Type A Behavior were used to achieve anger scores of the patient groups before surgery and four days after surgery.

Results: Baseline preoperative characteristics and operative variables were similar between the groups. Based on the preoperative test results, total anger scores were similar in both groups, however, it was significantly lower in group 2 in the postoperative period (p<0.001). The total anger scores significantly increased in group 1 after surgery. Pre- and postoperative state anger scores were significantly different between the patient groups. In group 2, the state anger score was not increased after operation, while the repressed anger (Ax-In) was significantly lower postoperatively (p<0.001). Postoperative trait anger was similar between the groups.

Conclusion: We suggest that education of patients on anger management before CABG is critical which may affect surgical prognosis positively and shorten the duration of hospital stay.

Coronary heart disease (CHD) is the most common cause of mortality in the world. Psychosocial, biochemical, and genetic factors are among the known etiologic factors, and to obtain the maximum benefits, all of these factors should be considered when deciding on a treatment strategy. It is known that anger, anxiety, and depression increase mortality and morbidity cases involving CHD,[1,2] but there is insufficient research regarding the postoperative anger and anxiety status of these patients. In this prospective study, we evaluated the effects of preoperative anger management education and psychological support as they related to anger management in patients who underwent coronary artery bypass graft (CABG) surgery.


This prospective, randomized, controlled study was conducted on volunteers who underwent CABG between September 2012 and January 2013 under elective conditions. In addition, we explained the study details to all of the participants and obtained their written informed consent. The local ethics committee also gave their approval. Initially, 80 patients were to be included in the study, but 12 were excluded due to wrong or incomplete coding, leaving a total of 68 patients.

The participants were randomly allocated into one of two study groups based on protocol numbers. Group 1 was composed of odd-numbered patients while those with even numbers made up group 2. Group 1 (18 males, 16 females; mean age 55.0±8.7 years; range 43 to 78 years) received routine preoperative care and then underwent CABG, whereas group 2 (17 males, 17 females; mean age 54.9±9.1 years; range 41 to 81 years), in addition to a preoperative education session a day before the surgery, also received a 30-minute educational session on anger management and psychological support on postoperative day one. Furthermore, for group 2, ward nurses were also educated by nursing instructors and hospital psychologists about possible postoperative problems.

In order to evaluate the pre- and postoperative anger status of the patients, we used a sociodemographic form (10 questions), an eight-question ERCTA (Escala Retiro de Patrón de Conducta Tipo A) that uses a scale to assess type A behavior, and the 57-question State-Trait Anger Expression Inventory-2 (STAXI-2). The patients filled out the forms the day before the surgery and again on the fourth postoperative day, and they also gave positive suggestions without giving unnecessary details. Furthermore, all of the participants filled out the questionnaires without any outside help. The instructions were given verbally but were also available in written form. Each question of the ERCTA received a score of between one and five points; thus, the total scores ranged from a low of eight to a maximum of 40 for each patient. Those who scored higher than 22 were accepted as having a type A personality.

All of the patients underwent CABG with nonpulsatile extracorporeal circulation [cardiopulmonary bypass (CPB)] using mild-to-moderate hypothermia (esophageal temperature 26-28 °C) and antegrade cold blood cardioplegia. Furthermore, the pre- and postoperative routine patient care processes were the same for both groups. Those who completed less than 75% of the questionnaires were excluded from the study. In addition, patients who were illiterate or those with psychotic disorders, dementia or mental retardation, or neurological problems in the postoperative period were not included as well as those patients who underwent revision surgery due to bleeding, those who had used psychotropic drugs for more than one year, and those with a malignancy. Furthermore, deceased patients were also excluded from our study.

The total anger index (Ax-index) of the STAXI-2 was calculated using the following formula in which Ax/con represents the anger control subscale, Ax-out the anger expression subscale, and Ax-in the internal anger subscale showing repressed anger.

Ax-index= 48+[(Ax-out)+(Ax-in)]-[(Ax/con-out)+ (Ax/con-in)]

The total scores ranged between 105 and 276, and the subscale scores varied between eight and 32.

Statistical analysis
The data was expressed using descriptive statistics [mean, standard deviation (SD), and percentages]. The homogeneity of the study groups and intergroup comparisons were conducted using a chi-square test and a t-test, whereas repeated measures analysis of variance (ANOVA) was used for intragroup comparisons. Additionally, the internal consistency of the questionnaires was analyzed using Cronbach’s alpha reliability test, and a p value of lower than 0.05 was accepted as being statistically significant.


The two study groups were similar in terms of age, gender, and education level as well as the number of patients with morbid obesity, a history of smoking, diabetes mellitus (DM), chronic lung disease, and kidney disease (p>0.05). Furthermore, the functional capacity based on the classification of New York Heart Association (NYHA), blood cholesterol levels, and family histories along with the number of patients with accompanying peripheral vascular diseases and cerebrovascular disorders were also similar (p>0.05) (Table 1). The groups were also compared according to their operative data, and the patients were evaluated based on their educational background. We determined that the study groups were similar in terms of crossclamp time, CPB time, cerebrovascular events, and number of bypasses (p>0.05), but the intubation time, length of time in the intensive care unit (ICU), and hospitalization time were significantly shorter in group 2. The operation data and postoperative complications are summarized in Table 2.

Table 1: Comparison of the demographic and clinical data between the study groups

Table 2: Procedural data for the study groups

In addition, we found that the internal consistencies of the ERCTA and STAXI-2 were quite good (see Table 3 for Cronbach’s alpha scores). Furthermore, the preoperative Ax-index was similar for both groups, but it was significantly lower after the operation in group 2. The State (S) Anger differed significantly in both the pre- and postoperative measurements, and the increase in this score of group 2 could not attributed to the surgery. The post-test results of the Ax-index, S anger, Ax-in, and Ax-out subscales between the two groups were significantly different (p<0.05); however, the Trait (T) anger results were similar. The groups were also similar in terms of type A personality as determined by the ERCTA before and after surgery (p>0.05). Table 4 shows the relationship between the subscale results and type A personality characteristics and reveals that the Ax-index and Ax-in scores of group 2 were significantly reduced in the post-test evaluation (p<0.05) (Table 5). In addition, the 30-day mortality rate in our study was zero.

Table 3: Between-group comparison of the internal consistency of the ERCTA and STAXI-2 scales

Table 4: Differences between the preoperative and postoperative tests


The relationship between individual health and personality characteristics is known, and the evidence available to support the strong correlation between personality-based characteristics, such as type A behavior, anger and stress, and cardiovascular disorders, is increasing. Many patients experience serious psychological problems due to fear of death and surgical trauma; therefore, their treatment costs are higher. Furthermore, some patients are not able to return to their daily routine until much later, which results in a loss of labor power.[3] In CHD patients, the incidence of the accompanying anger control disorder and mood disorders (major depression, minor depression, and dysthymia) has been reported as being between 5-10% and 10-15%, respectively.[4,5] In addition, anger and anxiety may lead to atherosclerotic plaque rupture, coronary vasospasms, and fatal ventricular arrhythmias.[6-8] Hyperventilation caused by increased anger levels has also been shown to result in vasospasms and arrhythmia, even in healthy individuals.[8,9] In addition, some studies have reported that anger may lead to a ventricular ectopic beat and tachycardia, which can lead to myocardial infarction.[10-12] A change in cerebral activity during emotional stress can also lead to the presence of nonhomogenous repolarization fields as the electrical stability deteriorates.[13,14] Moreover, repressed anger can lead to strong internal stress that may subsequently cause somatic problems. Transient increases in blood pressure may also stem from acute developing anger, but providing education related to anger management could result in a reduction in blood pressure.[15]

In this study, we found that CABG surgery increases the total Ax-index, but our research indicated that preoperative anger management education can have a beneficial effect on postoperative recovery. In fact, we believe that giving these patients this type of education in conjunction with psychological support may even shorten ICU and hospital stays. Furthermore, educating patients preoperatively about anger management may also decrease the pre- and/or postoperative S anger scores. However, the T anger scores showed no change after our efforts at education, whereas all of the other anger subgroup scores decreased.

A person with a type A personality may be enthusiastic, hasty, aggressive, impatient, and competitive and are extremely dedicated to their work. Additionally, these individuals experience many problems associated with different dimensions of anger (emotional, verbal, S and T anger, and anger expression). In this study, the ERCTA scores and T anger scores were high in both the pre- and postoperative measurements of all patients.[16,18]

We also observed that as the patients planned for the CABG, they became anxious because they of their fear of death, thus indicating their need for psychological support. However, psychological factors are usually not considered as part of the daily routine of cardiac patients, even though they are very important.[7] The intubation time and length of ICU and hospital stays were significantly shorter in patients who attended the 30-minute preoperative education session. Therefore, we suggest that the lack of availability of this type of education and psychological support may adversely affect a patient’s prognosis. In our study group, the physicians, who were blinded to the groups, made the decision to extubate the patient, transfer the patient from the ICU, or discharge the patient from the hospital.

The STAXI-2 is the gold standard for evaluating patients’ preoperative anger levels,[19,20] but to the best of our knowledge, it has not been used in the past to analyze anger in CABG patients. In our study, the preoperative T anger levels were high in patients who needed CABG surgery, and their were increased T anger scores in both groups, indicating that T anger cannot be changed by education or psychological support. However, our efforts at education did manage to reduce the total Ax-index scores in type A individuals. Because of this lack of change in the T anger scores, we hypothesize that this type of anger is the result of various genetic factors. The S anger and Ax-in levels were significantly reduced by the education offered to group 2; thus, we believe that preoperative education and counseling can significantly reduce the problems encountered during the postoperative care period.

This study is important because it demonstrates the role that preoperative education can play in reducing the fear and anger that stem from the patients’ fear of death and uncertain prognoses. In addition, our research also showed that education is more effective in patients who are over the age of 50.


Education is comprised of teaching patients how they will feel after the operation and explaining to them where they will be when they wake up, which functions they might lose and for how long, the reason for the tubes or drains in his body after the operation, and how to cope with postoperative pain. Giving patients an adequate education before surgery is crucial and can influence the surgical prognosis. Furthermore, offering psychological support has been proven to have a positive effect on anger management and provides the patient with valuable coping strategies. Our results showed that preoperative interviews and education along with good communication can facilitate better anger management in patients who are candidate for CABG.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

The authors received no financial support for the research and/or authorship of this article.


1) Carney RM, Freedland KE. Depression, mortality, and medical morbidity in patients with coronary heart disease. Biol Psychiatry 2003;54:241-7.

2) Cebeci F, Celik SS. Effects of discharge teaching and counseling on anxiety and depression level of CABG patients. Turk Gogus Kalp Dama 2011;19:170-6.

3) Strik JJ, Denollet J, Lousberg R, Honig A. Comparing symptoms of depression and anxiety as predictors of cardiac events and increased health care consumption after myocardial infarction. J Am Coll Cardiol 2003;42:1801-7.

4) Suls J, Bunde J. Anger, anxiety, and depression as risk factors f or c ardiovascular d isease: t he p roblems a nd implications of overlapping affective dispositions. Psychol Bull 2005;131:260-300.

5) Yapici N, Coruh T, Kehlibar T, Yapici F, Tarhan A, Can Y, et al. Dexmedetomidine in cardiac surgery patients who fail extubation and present with a delirium state. Heart Surg Forum 2011;14:E93-8.

6) Coulter SA, Campos K. Identify and treat depression for reduced cardiac risk and improved outcomes. Tex Heart Inst J 2012;39:231-4.

7) Vural M, Satiroglu O, Akbas B, Goksel I, Karabay O. Coronary artery disease in association with depression or anxiety among patients undergoing angiography to investigate chest pain. Tex Heart Inst J 2009;36:17-23.

8) Iskesen I, Yıldırım F, Sirin H. Neurocognitive effects of cardiopulmonary bypass in coronary artery bypass surgery. Turk Gogus Kalp Dama 2007;15:275-80.

9) Kervan U, Cicekcioglu F, Tuluce H, Ozen A, Babaroglu S, Karakas S, et al. Comparison of neurocognitive functions after beating-heart mitral valve replacement without aorta cross-clamping and after standard mitral valve replacement with cardioplegic arrest. Heart Surg Forum 2011;14:E335-9.

10) Sanders KM, Cassem EH. Psychiatric complications in the critically ill cardiac patient. Tex Heart Inst J 1993;20:180-7.

11) Ziegelstein RC. Acute emotional stress and cardiac arrhythmias. JAMA 2007;298:324-9.

12) Vlastelica M. Emotional stress as a trigger in sudden cardiac death. Psychiatr Danub 2008;20:411-4.

13) Critchley HD, Taggart P, Sutton PM, Holdright DR, Batchvarov V, Hnatkova K, et al. Mental stress and sudden cardiac death: asymmetric midbrain activity as a linking mechanism. Brain 2005;128:75-85.

14) Williams JE, Nieto FJ, Sanford CP, Tyroler HA. Effects of an angry temperament on coronary heart disease risk: The Atherosclerosis Risk in Communities Study. Am J Epidemiol 2001;154:230-5.

15) Williams JE, Paton CC, Siegler IC, Eigenbrodt ML, Nieto FJ, Tyroler HA. Anger proneness predicts coronary heart disease risk: prospective analysis from the atherosclerosis risk in communities (ARIC) study. Circulation 2000;101:2034-9.

16) Dimsdale JE. Psychological stress and cardiovascular disease. J Am Coll Cardiol 2008;51:1237-46.

17) Strike PC, Perkins-Porras L, Whitehead DL, McEwan J, Steptoe A. Triggering of acute coronary syndromes by physical exertion and anger: clinical and sociodemographic characteristics. Heart 2006;92:1035-40.

18) Fernandez F. Depression and its treatment in cardiac patients. Tex Heart Inst J 1993;20:188-97.

19) Demir A, Akyurt D, Ergün B, Haytural C, Yiğit T , Taşoğlu I, et al. Anxiety therapy in cardiac surgery patients. Turk Gogus Kalp Dama 2010;18:177-82.

20) Azevedo FB, Wang YP, Goulart AC, Lotufo PA, Benseñor IM. Application of the Spielberger's State-Trait Anger Expression Inventory in clinical patients. Arq Neuropsiquiatr 2010;68:231-4.

Keywords : Anger; coronary artery bypass grafting; management; patient education
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