The relationship of persistent post-surgery pain after cardiac surgery and anxiety, depression, and attachment style: a single center longitudinal study.

doi:10.21203/rs.3.rs-4294434/v1

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The relationship of persistent post-surgery pain after cardiac surgery and anxiety, depression, and attachment style: a single center longitudinal study.

https://doi.org/10.21203/rs.3.rs-4294434/v1

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Background: The development of persistent post-surgical pain (PPSP) is an important issue in cardiosurgery, as it can both predict and result from psychological phenomena such as depression or anxiety. This study aimed to identify differences between cardiac surgery patients with and without PPSP at 3- and 12-months post-surgery in various psychological domains.

Methods: This is a single-center prospective longitudinal study. N = 125 patients who underwent cardiac surgery in the years 2018-2020 at the Department of Cardiac Surgery of the 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic, were psychologically examined before the operation and by surface mail 3 and 12 months after the operation. Postoperative pain intensity was measured using a visual analog scale (VAS), Pain Map localization, Beck Depression Inventory-II (BDI-II) to measure depression, and Generalized Anxiety Disorder Assessment (GAD-7) to measure anxiety, to assess the relationship The Relationship Questionnaire (RQ). Patients were divided into two groups: the first, which met the criteria for persistent postoperative pain (PPSP), and the second, which had no PPSP. N = 94 patients responded 3 months after surgery and N = 72 patients 12 months after surgery.

Results: 3 months after surgery there were N = 67 (71.28%) patients with PPSP and N = 27 (28.72%) without PPSP, 12 months after surgery there were N = 44 (61.11%) patients with PPSP and N = 28 (38.89%) patients without PPSP. The results showed that patients with PPSP in both measurements had a significantly higher level of intensity of pain and discomfort (P < 0.001, P < 0.001), depression (P < 0.001, P < 0.001) and anxiety (P < 0.001, P < 0.001) as well as a higher probability of insecure attachment (P = 0.011), were more often female (P = 0.020, P = 0.005) and older than those without PPSP (P = 0.031).

Conclusions: This study is the first to prospectively examine the psychological factors associated with PPSP in Czech cardiac surgery patients over a 12-month period. Such studies could help provide valuable information for preventive interventions in individuals in postoperative pain control and in individuals with postsurgical persistent pain targeting anxiety, depression, and adult attachment styles.

persistent post-surgical pain

anxiety

depression

attachment style

The topic of persistent post-surgical pain (PPSP) in cardiac surgery and its relevance to psychology has recently grown in importance. Approximately 60% of cardiac surgery patients diagnosed with depression or anxiety disorder develop PPSP [1, 2, 3], but PPSP also has psychosocial consequences such as increased depressive [4] and anxiety symptoms [5], pain catastrophizing [6], or avoidant behavior [7]. These factors play a significant role in the individual’s quality of life, contact with healthcare professionals, and response to treatment. Many of the psychosocial consequences of chronic pain can promote or exacerbate chronic pain over time [8]. Still, medical, or psychological research remains limited on this issue.

The International Association for the Study of Pain (IASP) lists the following criteria that must be met for the pain to be classified as post-surgical and persistent: pain develops after surgery, pain persists for at least three months, other possible causes of pain have been ruled out, and the possibility of continuing preexisting, surgery independent pain has been ruled out [9].

Depression and anxiety appear to be the most prevalent predictors of PPSP development [1, 2, 3]. Preoperative anxiety is involved in the development of PPSP not only directly, but also indirectly through its effect on acute post-surgical pain [10]. Similarly, preoperative depression has both direct and indirect effects. In addition to the history of antidepressant use being a separate risk factor for the development of PPSP after cardiac surgery [2], preoperative depression is also associated with the experience of less hope postoperatively, which is another risk factor for developing persistent pain [11]. A recent study showed a relationship between preoperative anxiety and self-reported factors such as intensity of pain and discomfort, while preoperative depression seems to be related to objectively measurable outcomes such as increased mortality and subsequent acute re-admissions [12].

Studies on anxiety’s link to PPSP have yielded mixed results. While some studies suggest that a history of anxiety disorder or subclinical anxiety is a reliable predictor of PPSP development [13], others indicate that only preoperative anxiety, as an acute response to surgery, is involved in the development of PPSP [14]. Additionally, some researchers argue that mild to moderate preoperative anxiety, rather than trait anxiety, can activate adaptive coping strategies and alleviate the effect of the procedure as a stressor on subsequent healing of the patient [15].

Besides the affective factors, adult attachment style is considered to be a factor influencing the development of persistent pain both directly through a lowered pain threshold and hightened sensitivity to pain intensity [16, 17] and indirectly through its influence on the emotional response to pain, choice of coping strategies [18], catastrophizing pain, avoiding activities [19], self-perception [20] and cognitive assessment of pain [21]. Attachment style is also one of the factors predicting the extent to which chronic pain will lead to disability [20]. Moreover, attachment style appears to significantly affect the effectiveness of interventions targeting the psychological consequences of chronic pain, such as increased depression and anxiety levels [22]. However, not all studies have confirmed an association between attachment style and the development of chronic pain or subsequent disability [21, 22, 23], and a lack of studies in this area does not allow for a clear conclusion.

The literature suggests [1, 2, 3, 4, 5, 8, 10, 11, 12, 13, 14, 15, 16, 17, 22] that the degree of depression and anxiety, as well as adult attachment style, are important factors in how chronic pain develops and manifests and can affect a person's life after surgery. This study aims to provide more clarity to this research by determining whether there is a difference between cardiac surgery patients with and without postsurgical pain developed at 3 and 12 months after the surgery in affective, relational, clinical, demographic, or pain-related variables. Additionally, the study aims to ascertain whether these variables can be considered predictors of PPSP in these patients and whether different levels of anxiety and depression are related to the presence or absence of PPSP. Finally, the study aims to identify different trajectories of anxiety and depression based on the initial level of anxiety and depression and on the presence or absence of PPSP.

Participants. This is a cross-sectional single center and longitudinal design study that took place between the years 2018 and 2020. Participants were patients of the Department of Cardiac Surgery the 3rd Medical Faculty of Charles University and University Hospital Kralovske Vinohrady in Prague undergoing cardiac surgery at this department. The criteria for including the individual in the research were as follows: indications for heart surgery, no previous history of cardiac surgery, more than 18 years old, fluent in Czech, and sufficient cognitive functioning. The day before surgery, the patients were examined by a clinical psychologist (VAS, The pain map, BDI-II, GAD-7, RQ), anamnestic and sociodemographic data were collected. VAS pain intensity and pain discomfort were also recorded at the time of discharge. Questionnaires were subsequently sent to participants by surface mail at intervals of 3 and 12 months after surgery. All participants signed an informed consent, and the research was approved by the ethics committee of University Hospital Kralovske Vinohrady in Prague (FNKV EK - VP/53/02017).

Methods

The psychological methods were selected based on their previous use in research on postsurgical chronic pain in cardiac surgery patients.

Pain was evaluated using the Visual Analog Scale (VAS), which is a one-dimensional, single-item method designed to assess the intensity of currently experienced pain [24]. The respondent is asked to mark a point on a 10 cm long scale to indicate the intensity and discomfort of his/her pain currently or in the last 24 hours. A higher score indicates a greater intensity/discomfort of pain.

The Pain map [25] is a tool designed to localize pain. The map contains four images of the human body, front, back, left side, and right side. The subject is asked to circle the areas where he or she is currently feeling pain.

Beck´s Depression Inventory-II (BDI-II) is an inventory designed to assess the severity of depressive symptoms as defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) [26]. The subject is asked to evaluate the severity of their symptoms over the last two weeks using a four-point scale ranging from 0–3 points. The inventory consists of 21 items, with a total score between 0 and 63 points [34]. We evaluated as no depression BDI-II < 14 and present depression BDI-II ≥ 14.

To assess generalized anxiety disorder, the Generalized Anxiety Disorder Assessment (GAD-7) was employed. This is a self-assessment screening questionnaire consisting of 7 items, to which the subject responds on a four-point scale from 0 to 3 points. The highest possible score is 21 points, with higher scores indicating higher levels of generalized anxiety. The items ask about the frequency of feelings of nervousness or irritability, uncontrollable worries, difficulty resting, or worries about the future in the last 2 weeks [35]. We evaluated as no anxiety GAD-7 < 5, mild anxiety GAD-7 = 5–9, moderate anxiety GAD-7 ≥ 9.

The Relationship Questionnaire (RQ) is a self-assessment consisting of four items designed to determine the style of adult attachment and its intensity on a 7-point scale [27]. It is based on four category model of adult attachment style. A secure: high self-worth, believes that others are responsive, comfortable with autonomy and in forming close relationships with others, B fearful: negative self-view, lack of trust in others, subsequent apprehension about close relationships and high levels of distress, C preoccupied: a sense of self-worth that is dependent on gaining the approval and acceptance of others, D dismissing: overt positive self-view, denies feelings of subjective distress and dismisses the importance of close relationships.). Self-model and other-model perception scores were calculated for graphical representation.

Operationalization of persistent post-surgical pain (PPSP) in this study

The definition of persistent post-surgical pain (PPSP) adopted in this study was pain present in the chest or leg that was not present before surgery or that was present before the surgery and worsened by at least 20% after the procedure at either the 3 or 12 months follow up postoperatively. The pain intensity and location were measured using a visual analog scale (VAS) and a pain map. For patients who already had pain before the surgery, VAS was used to determine whether the pain deteriorated after the procedure. This definition of PPSP is based on a research project by Pagé, Watt-Watson, and Choiniere [28]. Depression was operationalized as a total score of at least 14 in the BDI-II, and anxiety was defined as a total score of at least 6 in the GAD-7.

Statistical analysis

To evaluate the difference between groups with and without PPSP, descriptive statistics, parametric t-tests, and chi-square tests were performed. Differences in the presence of PPSP between the depressed/anxious and non-depressed/anxious groups were assessed using a chi-square test and contingency tables due to the presence of categorical variables. In cases of zero frequencies, Haldan correction was applied. Cohen's d was used as the effect size for the t-test, and phi (φ) was used as the effect size for the chi-square test. Logistic regressions were performed to examine the relationship between specific variables (affective, attachment style, clinical, demographical, and pain) and the presence of the PPSP. To analyze the trajectories of anxiety, a statistical ANOVA test was used to generate a graphical representation. All statistical analyses using the IMB SPSS Statistics program. All tests were performed at a significance level of α = 0.5.

Of the 152 patients eligible for the study, 13 refused to participate and did not sign the informed consent form, and 13 patients were excluded for the impaired score in cognitive testing. This means that 126 patients entered the study between the years 2018 and 2020. In the first follow-up 3 months after surgery, data were collected from 94 subjects. 10 subjects did not respond, 5 patients passed away and 17 subjects were unavailable at the original address. In the second follow-up 12 months after surgery, data were collected from 72 subjects. 5 subjects did not respond, 1 patient passed away and 16 patients were unavailable at the original address. The detailed flow of the participants is summarized in Fig. 1. Participants were more often men, the average age in the group was 67.01 years. Most participants had a secondary education, only a third of them were employed, and most of the unemployed were retired. Married people were prevalent in the group. Detailed clinical and surgical characteristics of the participants are summarized in Table 1.

Table 1

Demographical, clinical, and pre-surgical psychological characteristics (N = 126)
variables	N (%) / M (±)
Age (years)	67.01 (± 8.38)
Gender (male)	97 (76.98%)
Education duration (years)	12.87 (± 2.80)
Employed Yes	33 (26.19%)
Social status
Married	80 (63.49%)
Single	7 (5.56%)
Widowed	13 (10.32%)
Divorced	26 (20.63%)
Smoking regularly	29 (23.02%)
Drinking regularly	58 (46.03%)
BMI	30.99 (± 17.37)
Comorbidities
History of stroke	20 (15.87%)
History of heart-attack	28 (22.22%)
Neurological/psychiatric	26 (20.63%)
Major surgery	63 (50%)
Oncological	15 (11.90%)
Hypertension	92 (73.02%)
Diabetes mellitus	49 (38.89%)
Type of surgery
Aortocoronary bypass	59 (46.83%)
Aortic valve surgery	15 (11.90%)
Mitral valve surgery	8 (6.35%)
Combined surgery	44 (34.92%)
Duration of cardiac difficulties (years)	3.40 (± 6.53)
Duration of hospitalization (days)	9.44 (± 7.55)
CRP after surgery	108.27 (± 78.94)
BDI-II	8.63 (± 7.24)
GAD-7	4.12 (± 3.65)
RQ
A	83 (73.45%)
B	8 (7.08%)
C	3 (2.65%)
D	19 (16.81%)
Note. BDI-II – Beck Depression Inventory-II, GAD-7 – Generalized Anxiety Disorder Assessment, RQ – Relationship Questionnaire, A-secure attachment, B-fearful-avoidant, C-preoccupied, D-dismissing-avoidant (missing data BDI-II N = 4, GAD-7 N = 2, RQ N = 13)

Outcome 3 months after Surgery. There was a statistically significant difference between a group of respondents with PPSP (N = 67, 71.28%) and a group of respondents with no PPSP (N = 27, 28.72%) 3 months after surgery in affective, relational, and pain-related characteristics, as well as some clinical and demographical characteristics. Results are summarized in Table 2. A significant difference was found between the groups in the gender variable (P < 0.020) with the low effect size φ = 0.240; women were more common in the PPSP group (91%) than men (65%). A significant difference was found in the intensity and discomfort of the pain; both variables have a significantly higher mean (P < 0.001) in the group with PPSP and very large-huge effect size d, (pain intensity M = 2.86, pain discomfort M = 2.54, d = 1.427) than in the group without PPSP (pain discomfort M = 0.36, pain intensity M = 0.44; d = 1.220). Furthermore, a significant difference (P < 0.001) was found in the rate of depression (BDI-II), with a higher mean rate of depression in the group with PPSP (M = 10.62) than in the group without PPSP (M = 5.51) with the large effect size d = 0.701, and in the level of anxiety (P < 0.001) with the small effect size d = 0.195, as determined by the results GAD-7, with a higher average level of anxiety in the group with PPSP (M = 4.57) than in the group without PPSP (M = 1.07), and in the significant intensity of individual styles of adult attachment according to the RQ questionnaire (P = 0.005, the medium-large effect size d = 0.672), with secure attachment style having a lower average intensity in group with PPSP (M = 4.39) than in the group without PPSP (M = 5.37), while the other insecure attachment styles have a significant higher average intensity in the group with CPSP (P = 0.031–0.039, with the medium effect size d = 0.486–0.514). Further details on the distribution of attachment types before surgery, 3 and 12 months after surgery concerning PPSP are shown in Fig. 2. No significant difference was found in the level of CRP, length of hospitalization, age, and length of education, as well as in the style of adult attachment (P > 0.05).

Table 2

Differences between PPSP and no-PPSP groups 3 months after surgery (N = 94)
Characteristics	PPSP (N = 67)	no-PPSP (N = 27)	t / χ²	p	Effect size
	M (± / N (%)	M (±) / N (%)
Duration of hospitalization (days)	8.82 (± 6.08)	11.11 (± 12.17)	-1.211^a	.229(	.238^d
Age	67.12 (± 7.91)	68.07 (± 8.37)	-0.521^a	.604	.117^d
Education duration (years)	13.43 (± 3.16)	12.78 (± 2.41)	0.958^a	.340	.231^d
Gender			5.407^b	.020	.240^p
Female	20 (90.91%)	2 (9.09%)
Male	47 (65.28%)	25 (34.72%)
VAS pain intensity	2.86 (± 2.11)	0.44 (± 0.11)		< .001	1.427^d
VAS pain discomfort	2.54 (± 2.33)	0.36 (± 0.97)		< .001	1.220^d
BDI-II	10.62 (± 9.16)	5.52 (± 4.68)	2.746^a	< .001	.701^d
GAD-7	4.58 (± 4.95)	1.07 (± 2.22)	3.526^a	< .001	.195^d
RQ attachment style			6.119^b	.106	.255^p
A	38 (62.30%)	23 (37.70%)
B	8 (88.89%)	1 (11.11%)
C	6 (85.71%)	1 (14.29%)
D	13 (86.67%)	2 (13.33%)
RQ style intensity
A	4.39 (± 1.59)	5.37 (± 1.31)	-2.827^a	.005	.672^d
B	2.71 (± 1.64)	1.93 (± 1.41)	2.177^a	.032	.510^d
C	2.70 (± 1.74)	1.96 (± 1.27)	2.088^a	.039	.486^d
D	3.35 (± 1.96)	2.41 (± 1.69)	2.185^a	.031	.514^d
CRP after surgery	103.85 (SD 84.93)	106.64 (SD 65.29)	-0.153^a	.878	.037^d
Note. BDI-II – Beck Depression Inventory-II, GAD-7 – Generalized Anxiety Disorder Assessment, RQ – Relationship Questionnaire, A-secure attachment, B-fearful-avoidant, C-preoccupied, D-dismissing-avoidant, CRP -, ^a = t-test, ^b = chi-square, ^d = Cohen´s d, ^p = phi coefficient, significant results are bolded.

Outcome 12 months after Surgery. There was a statistically significant difference between a group of respondents with PPSP (N = 44, 61.11%) 12 months after surgery and a group of respondents with no PPSP (N = 28, 38.89%) 12 months after surgery in affective, relational, and pain-related characteristics, as well as some clinical and demographical characteristics. Results are summarized in Table 3. A significant difference (P < 0.005) was found between the groups in the gender variable with the medium effect size φ = 0.329; women were more common in the PPSP group (89%) than men (52%). A significant difference was found in the intensity and discomfort of the pain (P < 0.001, P < 0.001) with the huge effect size d; both variables have a significantly higher mean in the group with PPSP (intensity M = 4.06, discomfort M = 4.55, with the d = 1.495) than in the group without PPSP (intensity M = 0.77, discomfort M = 0.85, d = 1.470). Furthermore, a significant difference was found in the rate of depression (P < 0.001), as determined by the BDI-II results, with a higher average rate of depression in the group with PPSP (M = 13.65) than in the group without PPSP (M = 6.92) with the large effect size d = 0.891, and in the degree of anxiety (GAD-7) (P < 0.001, large effect size d = 0.928), with higher mean anxiety in the PPSP group (M = 4.52) than in the non PPSP group (M = 1.14), and based on age (P < 0.031), with a lower mean age in the PPSP group (M = 65.52) than in the without PPSP (M = 69.57) with the medium effect size d = 0.459. A significant difference between groups was also found in the intensity of secure attachment style (P < 0.023, medium effect size d = 569), with a lower average intensity in the group with PPSP (M = 4.30) than in the group without PPSP (M = 5.29), but not in the intensity of other styles (P > 0.05). A significant difference was also found regarding the general attachment style of adults (P < 0.011, with the small-medium effect size d = 0.390); in the group with PPSP, the secure attachment style is less represented (48%) and among the insecure attachments, the D - dismissing avoidant style is more represented (84%). No significant difference was found in the level of CRP, length of hospitalization, and length of education (P > 0.05).

Table 3

Differences between PPSP and no-PPSP groups 12 months after surgery (N = 72)
Characteristics	PPSP (N = 44)	no-PSP(N = 28)	t / χ²	p	Effect size
	M (±) / N (%)	M (±) / N (%)
Duration of hospitalization (days)	11.16 (± 11.45)	8.11 (± 4.19)	1.352^a	.181	.354^d
Age	65.52 (± 8.29)	69.57 (± 6.34)	-2.205^a	.031	.549^d
Education duration (years)	12.91 (± 3.44)	13.57 (± 2.43)	-0.888^a	.378	.222^d
Gender			7.792^b	.005	.329^p
Female	16 (88.89%)	2 (11.11%)
Male	28 (51.85%)	26 (48.15%)
VAS pain intensity	4.06 (± 2.57)	0.77 (± 17.46)		< .001	1.495^d
VAS pain discomfort	4.55 (± 2.93)	0.85 (± 20.09)		< .001	1.470^d
BDI-II	13.66 (± 9.56)	6.93 (± 4.77)	3.456^a	< .001	.891^d
GAD-7	4.52 (± 4.92)	1.14 (± 1.53)	3.526^a	< .001	.928^d
RQ attachment style			10.968^b	.011	.390^p
A	22 (47.83%)	24 (52.17%)
B	5 (100.00%)	0 (00.00%)
C	1 (50.00%)	1 (50.00%)
D	16 (84.21%)	3 (15.79%)
RQ styl intensity
A	4.30 (± 1.86)	5.29 (± 1.61)	-2.317^a	.023	.569^d
B	2.71 (± 1.62)	2.25 (± 1.48)	1.198^a	.235	.296^d
C	2.52 (± 1.52)	2.36 (± 1.66)	0.435^a	.665	.101^d
D	3.39 (± 1.85)	3.07 (± 2.11)	0.668^a	.506	.161^d
CRP after surgery	92.72 (± 87.35)	117.78 (± 86.36)	-1.186^a	.239	.289^d
Note. ^a = t-test, ^b = chi-square, ^d = Cohen´s d, ^p = phi coefficient, significant results are bolded

Trajectories of depression based on the initial level of anxiety and depression and the presence or absence of PPSP 12 months after surgery. While in the group that did not develop PPSP and did not show signs of depressive symptoms before surgery, the values in BDI-II and other measurements remained at a similar level, in the group without signs of depressive disorder, but with PPSP, the rate of depression steadily increased after the surgery (Fig. 3). Participants with pre-operative depression had similar trajectories regardless of whether or not they developed PPSP. In these patients, a significant decrease in depression between preoperative and 3-month measurements can be observed, followed by a very slight increase between 3 and 12 months, with the trajectory being lower for patients without PPSP, as patients scored overall less in BDI-II. However, the differences in depressive trajectories in respondents without preoperative depression and PPSP 3 months after surgery (M = 10.52) and 12 months after surgery (M = 12.60) and with preoperative depression and PPSP 3 months after surgery (M = 15.50) and 12 months after surgery (M = 17.33) were not significant in the first follow-up, (P = 0.096) nor in the second follow-up (P = 0.111).

Trajectories of anxiety based on the initial level of anxiety and depression and on the presence or absence of PPSP 12 months after surgery. In anxiety trajectories (Fig. 4), in the group without PPSP and no pre-surgical anxiety the level of anxiety remained approximately the same throughout, while in the group with PPSP, a gradual increase in the level of anxiety can be observed. In the case of mild anxiety, in the group with PPSP, there is a slight increase in anxiety in the first follow-up, and then a more significant decrease in the second follow-up. The group without PPSP and with mild anxiety showed a sharp decrease in anxiety symptoms in the first follow-up and after 12 months there was almost no difference between this group and the group with no preoperative anxiety. As for moderate anxiety, data were only available from respondents with PPSP. Thus, all respondents with preoperative anxiety greater than 9 points in GAD-7 developed PPSP. The anxiety trajectory in this group was very similar to the anxiety trajectory in the group without PPSP and with mild anxiety, only this trajectory was shifted higher because people in this group generally scored more in GAD-7. Differences in anxiety trajectories in the group of respondents without preoperative anxiety and PPSP 3 months after surgery (M = 3.9) and 12 months after surgery (M = 4.2) and with mild anxiety and PPSP 3 months after surgery (M = 6.9) and 12 months after surgery (M = 4.4) were significant in the first follow-up (P = 0.014), but not in the second one (P = 0.879). Differences in anxiety trajectories in respondents with mild anxiety and PPSP 3 months after surgery (M = 6.9) and 12 months after surgery (M = 4.4) and with moderate anxiety and PPSP 3 months after surgery (M = 5.3) and 12 months after surgery (M = 5.0) were not significant in the first (P = 0.392) nor second (P = 0.729) follow-up, as well as differences in trajectories in respondents with moderate anxiety and no anxiety (P = 0.465 and P = 0.633).

Levels of anxiety and depression related to the presence or absence of PPSP. As for the hypotheses about different levels of anxiety and depression being related to the presence or absence of PPSP, there was no significant difference between the groups with and without depression in the presence of PPSP 3 months after surgery (P = 0.879); in the group with PPSP were 83% without depression and in the group without PPSP were 82% without depression. There was also no significant difference between the non-depressed group, and depressed group in the presence of PPSP 12 months after surgery (P = 0.719); in the group with PPSP were 85% without depression and in the group without PPSP were 82% without depression. There was close but no significant difference between the groups without anxiety, with mild anxiety, and with moderate anxiety 3 months after surgery (P = 0.075). In the group with PPSP, 58% were without anxiety, 34% with mild anxiety, and 8% with moderate anxiety, and in the group without PPSP, 82% were without anxiety, 11% with mild anxiety, and 7% with moderate anxiety. There was a significant difference between these groups in the presence of PPSP 12 months after surgery (P = 0 .049); the incidence of PPSP was 57% in the group without anxiety, 31% in the group with mild anxiety, and 12% with moderate anxiety, whereas in the group without PPSP, 82% were without anxiety and 18% were with mild anxiety.

Predictors of PPSP. Several logistic regression analyzes were performed to test hypotheses about preoperative affective, attachment, and cardiological-clinical characteristics being predictors of PPSP 3 and 12 months after the surgery. Analyzes showed that values of presurgical depression, anxiety, and attachment do contribute, although not significantly, to the prediction of PPSP 3 or 12 months after surgery (P > 0.05). The neurological/psychiatric comorbidities significantly (β = 4.368, 95% CI [1.167, 16.350]; P = 0.029) and only closely hypertension would do contribute to the prediction of PPSP 3 months after surgery (β = 3.201, 95% CI [0.815, 12.567]; P = 0.095). The type of surgery closely can contribute to the prediction of PPSP 12 months after surgery (β = 1.439, 95% CI [0.939, 1.205]; P = 0.095). Preoperative and postoperative pain were only close significant predictors of PPSP in our study, intensity of postoperative intensity of pain (VAS) before discharge for PPSP in 3 months (β = 1.069, 95% CI [0.998, 1.146]; P = 0.059) and pain discomfort (VAS) for PPSP in 12 months after cardiac surgery (β = 1.080, 95% CI [0.998, 1.168]; P = 0.057).

The result of our research showed that there are significant differences in patients with and without PPSP in pain intensity and discomfort after surgery, degree of depression and anxiety, predominant adult attachment style, and gender.

The significant differences found in our study between groups of patients with and without PPSP are in line with differences found in previous studies. Namely, the pain intensity and discomfort were significantly higher in the group of patients with PPSP, which is something that was shown in other studies as well [29]. The degree of depression and anxiety was significantly higher in the PPSP patients, which is also a result in line with previous research [10, 29, 30, 31, 36, 37]. Predominant adult attachment style was also significantly different in between groups. Secure attachment appeared in much lower intensity in PPSP patients, whereas the dismissing-avoidant style appeared in significantly higher intensity in PPSP patients than in patients without PPSP. This confirms the results of previous studies [16, 17, 19, 40]. Our study has shown a significant gender difference, with women being more prevalent among PPSP patients, therefore also confirming the results of previous studies [32]. All of these differences were found 3 months after the surgery as well as 12 months after the surgery, which shows this is not a short-term issue but a question of long-term management.

There was a difference in trajectories of depression and anxiety in respondents with PPSP, which suggests there might be distinct profiles in cardiac surgery patients´ depression and anxiety development over a two-year postoperative period. This part of our study was based on the study by Pagé, Watt-Watson, and Choiniere [28]. There were some differences in our trajectories, mainly for respondents without preoperative depression or anxiety and for respondents with mild preoperative anxiety. It is possible that with a larger number of respondents and a longer period of observation, the trajectories would take on a similar shape as described by Pagé, that is the shape of an enlarged U.

In terms of predictors of PPSP, anxiety values were close to significant, therefore the results follow the same direction as previous studies [10, 13, 14, 16]. In our research, the anxiety values were much closer to significant than depression values, which is consistent with the precondition that anxiety is a stronger predictor of PPSP than depression [10, 28, 36, 37, 38, 39]. Values of preoperative and postoperative pain discomfort were also on the verge of significance and thus follow what has been shown in previous research [29, 33]. It is possible that with a larger number of respondents, the model would show some predictive power of these variables.

There are some limitations of our study. Regarding the method of data collection, self-assessment questionnaires were used, the results of which could be influenced by respondent personality characteristics. In the further development of this research, it would be beneficial to monitor the results of a larger number of respondents in a multicenter study. Objective assessment scales could be used to assess depressive and anxiety symptoms.

This study is the first to prospectively examine the psychological factors of chronic pain in Czech cardiac surgery patients in a 12-month period. Results suggest that there is a statistically significant difference between the groups with and without PPSP in the intensity and discomfort of pain, the level of depression and anxiety, age, gender, and attachment style, with the dismissing style being more prevalent among respondents with PPSP. The level of anxiety remained similar in both groups, while the level of depression increased in the PPSP group to the level of mild depressive disorder. Individuals with preoperative anxiety symptoms but not with depressive symptoms developed PPSP more often than individuals without any symptoms of affective disorder. Further studies extending the number of participants and the length of the study could help to clarify some of the results. Obtaining data not only on the presence of PPSP but on the extent to which pain affects the respondent's life, could also be a valuable additional component for future research. This work provides a stable basis for studies following the psychological aspects of PPSP in Czech cardiac surgery, which might help to clarify its risk factors and possible predictors, and therefore provide valuable information for future preventive interventions for people with PPSP.

persistent post-surgery pain (PPSP)

visual analog scale (VAS)

Beck Depression Inventory-II (BDI-II)

Generalized Anxiety Disorder Assessment (GAD-7)

The Relationship Questionnaire (RQ)

fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)

C-reactive protein (CRP)

Ethics approval and consent to participate. This is a cross-sectional single center and longitudinal design study that took place between the years 2018 and 2020. Participants were patients of the Department of Cardiac Surgery the 3^rd Medical Faculty of Charles University and University Hospital Kralovske Vinohrady in Prague undergoing cardiac surgery at this department. The study followed the ethical standards outlined in the Declaration of Helsinki. All participants signed an informed consent, and the research was approved by the ethics committee of University Hospital Kralovske Vinohrady in Prague (FNKV EK - VP/53/02017).

Consent for publication. Not applicable.

Availability of data and materials. The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests. The authors declare no competing interests.

Funding. This work is not associated with any direct funding sources.

Author contributions.

J.A. and R.J. designed the study, performed the experiments, collected and analyzed the data, and wrote the article,

B.J. and B.P. collected the data,

R.K. analyzed the data and wrote the article,

B.J., B.P., and V.G. critically reviewed the article.

All authors contributed significantly to the final version of the manuscript and all revisions.

All authors read and approved the final manuscript as submitted.

Acknowledgements. Not applicable.

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No competing interests reported.

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The relationship of persistent post-surgery pain after cardiac surgery and anxiety, depression, and attachment style: a single center longitudinal study.

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Operationalization of persistent post-surgical pain (PPSP) in this study

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