European Journal of Cardiovascular Nursing 1 (2002) 195201

Anxiety and well-being in first-time coronary angioplasty patients and

repeaters
Mattie J. Lenzena,*, Claudia J. Gamelb, Atie W. Imminka
a
Department of Cardiology, Thoraxcenter, Erasmus MC, Dr. Molewaterplein 40, 3015GD Rotterdam, The Netherlands
b
Department of Nursing Science, UMC-Utrecht and Faculty of Health Care, Hogeschool van Utrecht, Utrecht, The Netherlands

Received 14 January 2002; received in revised form 1 May 2002; accepted 17 July 2002

Abstract

Introduction: Preparatory information before an invasive procedure has positive effects (e.g. on recovery, well-being and
anxiety). However, preparation of patients for a repeat procedure is hardly investigated. The question is whether these patients
benefit from the same preparatory information. Aims: To determine whether there are differences in terms of anxiety and well-
being between patients undergoing their first percutaneous transluminal coronary angioplasty (PTCA) and those undergoing a
repeat PTCA. Design: Descriptive correlational study with a quantitative and qualitative research component. Method: First-time
PTCA patients (ns46) and re-PTCA patients (ns40) were asked to complete three psychological self-report questionnaires
(HADS, HPPQ and VAS) before the procedure. Five re-PTCA patients were interviewed the day after the procedure. Results: We
were not able to show statistically significant differences between the two groups. On the anxiety scales re-PTCA patients scored
6.5 (HADS) and 4.0 (VAS) vs. 5.0 (Ps0.25) and 2.6 (Ps0.30) for first-time PTCA patients. On well-being (HPPQ) these
differences were 18.0 vs. 19.0 (Ps0.40). Once the interview data were coded, four themes were apparent, namely: recurrent
symptoms, information, experience and future prospects. Conclusion: A trend is seen towards a worse condition in the re-PTCA
group with respect to anxiety and well-being. However, the differences are not statistically significant, they seem to be clinically
relevant. The interviews point out that the return of symptoms and future prospects, rather than the procedure itself, are an
important part in preparing for a repeat intervention. This aspect is currently no part of the provided preparatory information.
Future research will have to determine the most beneficial method of preparing these patients (e.g. tailored preparation, emotional
support, coaching).
2002 European Society of Cardiology. Published by Elsevier Science B.V. All rights reserved.

Keywords: Anxiety; Well-being; Angioplasty; Repeat intervention

1. Introduction dramatic developments and these have made it possible

Treating angina pectoris, an ischemic heart disease
caused by coronary sclerosis, is a major focus in
cardiology. Coronary sclerosis is a chronic and often
progressive disease. Over the past decades, tremendous
progress has been made in the methods of treatment. In
addition to medication therapy, invasive techniques have
been developed to achieve revascularisation: coronary
bypass surgery (CABG) was introduced in the late
1960s and percutaneous transluminal coronary angio-
plasty (PTCA) in the late 1970s. PTCA has undergone
*Corresponding author. Tel.: q31-10-4632891; fax: q31-10-
4089484.
E-mail address: lenzen@card.azr.nl (M.J. Lenzen).
to treat increasingly complex single-vessel and multi-
vessel diseases w1x. Comparative medical studies on
death, morbidity and the need for re-intervention in
CABG and PTCA patients reveal no significant differ-
ence in death and morbidity. PTCA patients, however,
have a greater need for re-intervention w2x. When a
repeat intervention is indicated, the question arises as to
whether these patients should receive the same type of
preparation as patients undergoing their first inter-
vention.
An important part of preparing patients for an invasive
procedure, such as an operation, a diagnostic examina-
tion or a PTCA, is the provision of information. The
presented information, in whichever form of transmis-

1474-5151/02/$ - see front matter 2002 European Society of Cardiology. Published by Elsevier Science B.V. All rights reserved.
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196 M.J. Lenzen et al. / European Journal of Cardiovascular Nursing 1 (2002) 195201
sion, should consist of procedural, sensory and behav-
ioural information w35x. After receiving preparatory
information, the patient is less likely to make his own
(wrong) interpretation about what he is facing. A wrong
interpretation paves the way for imaginary fantasies of
fear w6x. Measurable effects have been observed on
recovery, well-being, and a reduction in anxiety if the
preparatory information consists of procedural, sensory
and behavioural information w713x. Although the spe-
cialist is responsible for providing a large part of this
information, it is becoming increasingly more common
for the nursing staff to prepare patients for invasive
procedures and surgery w14x. More than 35 years after
the first nursing research article by Dumas and Leonard
w15x, preparation remains a highly topical subject, not
only in the daily practice but also in nursing research.
As briefly mentioned, a number of PTCA patients
require repeat intervention. If these patients benefit from
the same preparatory information is hardly investigated
w4,1618x. Most of the studies concerning preparatory
information focus on patients who have had no previous
experience with a specific medical procedure w912x.
The studies that do focus on previous intervention w16
18x do not clarify whether patients undergoing a repeat
intervention need the same or different preparation as
patients undergoing their first intervention. Although
these studies did not provide information with respect
to the way patients should be prepared for a re-interven-
tion, they addressed a number of quantifiable effects of
preparatory information in general. As these studies
shown a relationship between preparatory information
and measurable outcomes (e.g. recovery, anxiety and
well-being), the aim of the present study was to inves-
tigate whether there are measurable differences between
first-time intervention patients and repeat intervention
patients. We hypothesised that if re-PTCA patients had
a worse score on anxiety and well-being, this may
indicate that these patients do not benefit equally from
the method of preparation used. Secondly, we aimed at
gaining insight into the way in which patients prepare
themselves for a repeat intervention. With respect to
these aims, two research questions were formulated.
First, is there a quantifiable difference in pre-operative
level of anxiety and well-being between patients under-
going PTCA for the first-time and patients who have
already undergone a PTCA? Second, how do patients
prepare themselves for a repeat PTCA? Because the
self-regulation theory of Leventhal and Johnson w7x is
frequently used when preparing patients for their (first)
intervention, this theory was chosen as the theoretical
framework of this study. The self-regulation theory
clarifies the processes and effects of preparatory infor-
mation that consists of procedural, sensory and behav-
ioural information as well as coping instructions.
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2. Patients and methods
A cross-sectional, descriptive, correlational study with
a quantitative (first research question) and a qualitative
(second research question) research component was
used because of the nature of the research questions.
Ethics committee approval of the study was obtained.
All patients consecutively admitted to the Department
of Cardiology at the Academic Hospital of Rotterdam
for an elective planned PTCA as a result of an ischemic
coronary disease between the month of May and August
2000 were invited to participate in the study if they had
sound knowledge of Dutch. From a total of 96 admis-
sions for an elective PTCA, 86 met the inclusion criteria.
Ten patients were not eligible due to language problems
or participation in another study. Written informed con-
sent was obtained from all 86 patients.
2.1. Data collection methods
Three questionnaires were given to the respondents
before preparatory information was provided, however,
they were asked to fill in the questionnaires after the
information was provided. The questionnaires had to be
returned before the procedure. The questionnaires were
the (1) hospital anxiety and depression scale (HADS)
w19,20x; (2) the heart patients psychological question-
naire (HPPQ) w21,22x; and (3) a visual analogue scale
(VAS) w2325x. These questionnaires measure outcomes
that are frequently targeted when preparing patients for
threatening procedures. Also these outcomes are consis-
tent with the theoretical framework (Leventhal and
Johnson) of this study.
The HADS measures anxiety and depression in a
hospital environment. The 14 items in the questionnaire
are grouped in two sub-scales: Anxiety (7 questions)
and Depression (7 questions). Patients choose among
four possible answers, which are assigned a value (0
3). For each sub-scale, a minimum score of 0 and a
maximum score of 21 points is possible. The higher the
score, the higher the level of anxiety or depression. A
score 08 indicates at least borderline anxiety or depres-
sion w19x.
The HPPQ measures the mental well-being of heart
patients. It contains 52 items which patients rate on a
three-point Likert scale (13). Forty of the 52 items are
distributed among four sub-scales: Well-being (12 items,
score range 1236); Feelings of disability (12 items,
score range 1236); Despondency (10 items, score
range 1030); Social inhibition (6 items, score range
618). A high score in feelings of disability, despon-
dency and social inhibition indicates a worse condition,
with, respectively, 33, 21 and 14 as cut-off points. The
 M.J. Lenzen et al. / European Journal of Cardiovascular Nursing 1 (2002) 195201
opposite applies to the well-being dimension: the lower
the score the poorer the condition (cut-off point is 14)
w21x.
The VAS is particularly suitable for measuring the
intensity of subjective sensations, such as pain, fatigue,
or anxiety in patients with a heart disease w24x. A VAS
consists of a line, 100-mm in length. At each end of the
line are anchors, which represent the extremes of the
sensation under study. The patient is asked to mark a
point along this line. In the present study: I dont feel
anxious at all and I feel extremely anxious were used
as anchors.
An interim analysis of the results obtained with the
HADS and HPPQ was performed in order to select
which repeat PTCA patients to approach for an interview
(in order to answer the second research question). The
results with the first 24 patients revealed a significant
difference in well-being (HPPQ) in first-time and repeat
patients. Five patients, 2 with a low well-being score
and 3 with a high well-being score were asked for the
interview which took place the day after the procedure.
All agreed to participate. A semi-structured interview
technique was used w25x. The patients were confronted
with the same opening question: how did you feel
about having to undergo another angioplasty? The
following topics were explored: previous procedure,
approach by nurses and physicians, assistance with
preparation, influence of previous procedure, need for
information, influence of symptoms and future pros-
pects. The topics assistance with preparation and need
for information provided the opportunity to explore
preparation in the terms of the Leventhal and Johnson
framework.
2.2. Statistical analysis
For the quantitative analysis, SPSS for Windows (ver-
sion 9.0) was used. Data obtained on a nominal level
(among others, the basic characteristics of the sample)
were analysed with Pearsons x2-test. If the numbers
per cell were smaller than 5, Fishers Exact was used.
The results obtained with the HADS, HPPQ and VAS
were all on an interval level. Distribution was assessed
with the KolmogorovSmirnov test. Since a normal
distribution was not found, a non-parametric method of
analysis was used, namely the MannWhitney test. The
study results are therefore expressed in median values,
and distribution is given in the first (P25) and third
(P75) quartiles. A P-value of -0.05 (two-sided) was
considered statistically significant.
As dividing males and females is recommended in
studies involving psychological questionnaires w26x
these data were analysed separately for each gender. It
should be noted however, that exploring gender differ-
ences was not planned before data collection.
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197
Table 1
Basic characteristics of the sample size
Total 1e-PTCA re-PTCA P-value
ns86 ns46 ns40
Age in yearsa 60 60 (53y72) 58 (53y71) 0.61
Male 71% 65% 77% 0.21
Waiting period in weeksa 4.7 4.0 (3y6) 5.0 (3y6) 0.56
CABG 21% 13% 30% 0.05
a
Median scores, measure of variability is given in 25th and 75th
percentile.
The interviews were analysed according to the
approach described in the grounded theory w27x because
this method best suited the research question. Based on
symbolic interactionism, this theory takes reality to be
that which the respondent perceives and experiences as
being real. The interviews were analysed by transcrip-
tion, open coding, selective coding w25x, and finally a
number of concepts in development w28x were identi-
fied. In the findings, these concepts in development are
labelled by themes for practical purposes. Conform with
ensuring reliability and validity in qualitative research
the following procedures were followed: one interviewer
did all interviews, interviews were recorded and tran-
scribed, analysis and interpretations were discussed with
colleague researchers (peer debriefing).
3. Results
A total of 86 patients were enrolled in the study.
Characteristics of these patients are listed in Table 1.
The sample was predominantly male (71%). The median
age of the total group was 60 years, and waiting period
in weeks for the intervention was 4.7 weeks. A little
less than half of the respondents (47%) were admitted
to undergo a repeat intervention and 18 respondents
(21%) had previously undergone a bypass operation
(CABG). Statistical analysis of the basic characteristics
of the two groups, 1e-PTCA and re-PTCA, did not
reveal any significant differences in age, gender and
waiting period for the intervention. However, the number
of CABG operations in the respondents undergoing their
first PTCA is smaller than in the re-PTCA group (Ps
0.05).
All respondents (ns86) completed and returned the
questionnaires. Two respondents (one from each group)
did not entirely complete the HPPQ. As their sub-scale
scores could not be calculated, the HPPQ questionnaires
from these patients were excluded from analyses. Medi-
an scores are presented in Table 2.
The anxiety score (HADS) shows a trend towards a
worse condition in re-PTCA patients (Ps0.25).
A comparison between the two groups reveals a
slightly lower degree of well-being (HPPQ) in the re-
PTCA group (Ps0.40). The measure of feelings of
disability (HPPQ) demonstrates that there is a clear
198 M.J. Lenzen et al. / European Journal of Cardiovascular Nursing 1 (2002) 195201

Table 2
Differences between the 1e-PTCA and re-PTCA groups

Variables 1e-PTCA (ns46) re-PTCA (ns40) P-value

HADS Anxiety 5.0 (4.0y8.0) 6.5 (5.0y10.0) 0.25
Depression 5.0 (3.0y6.0) 4.5 (2.0y8.0) 0.73
HPPQa Well-being 19.0 (15.0y24.5) 18.0 (14.0y23.0) 0.40
Disability 33.0 (28.0y34.0) 32.0 (29.0y35.0) 0.88
Despondency 16.0 (13.0y19.5) 17.0 (14.0y22.0) 0.30
Social inhibition 11.0 (9.0y15.0) 11.0 (8.0y14.0) 0.62
VAS 010 cm 2.6 (0.7y6.4) 4.0 (1.2y6.0) 0.30
Median scores, measure of variability is given in 25th and 75th percentile.
a
HPPQ analysis is based on 84 questionnaires because two respondents (one from each group) did not entirely complete the questionnaire.

discrepancy between the desired and actual ability in a
large percentage of the respondents (in both groups).
The median in both groups is close to maximum score
of 36 (32.0 in re-PTCA vs. 33.0). A slightly worse
median score (Ps0.30) is seen in the 1e-PTCA group
when measuring despondency with the HPPQ. The last
sub-scale of the HPPQ is that of social inhibition.
Median scores between the groups are the same (11.0).
None of the above mentioned differences are statistically
significant.
The median VAS score is clearly higher in the group
of respondents undergoing a re-PTCA (4.0) than in the
other group (2.6), indicating higher anxiety levels in the
re-PTCA group. However, this is not a statistically
significant difference (Ps0.30).
The data obtained with the HADS and HPPQ also
were analysed for clinical implications using the estab-
lished cut-off points for these scales. As shown in Table
3 a greater percentage of the re-PTCA patients report at
least borderline anxiety (43% compared to 26%, Ps
0.11). The percentage of females with at least borderline
anxiety is greater than the percentage of males in both
the 1e-PTCA and re-PTCA group. On well-being, a
greater percentage of the respondents scored below the
given borderline value in the re-PTCA group than in the
1e-PTCA group (Ps0.16). In contrast to the previous
findings, the 1e-PTCA respondents scored slightly worse
on feelings of disability, than the re-PTCA respondents.
Between a third and almost half of the respondents
scored above the cut-off point ()33). A significant
difference (P-0.05) is seen between the groups in
patients that scored above the cut-off point in the sub-
scale despondency (HPPQ): 31% in the re-PTCA group
compared to 13% in the 1e-PTCA group. When broken
down per gender, it is clear that it is the male population
that causes this significant difference (7% vs. 29%). On
most of the sub-scales, females scored less favourably
than males.
As the literature does not provide a clinical implica-
tion cut-off point in analysing the VAS, no specific
value was used to differentiate between patients who
felt anxious and those who did not. Like in all previous
sub-scales, females felt more anxious than males.
In addition to the questionnaires, interviews were held
with 5 patients who were admitted for a re-PTCA. The
following themes were identified: recurrent symptoms,
information, experience and future prospects. With
respect to recurrent symptoms, the respondents had

Table 3
Differences in outcomes within the group all patients, males and females, in percentages of patients that score worse then the predefined cut-off
point, including gender differences

All patients Male gender Female gender

e e
1 -PTCA re-PTCA P-value 1 -PTCA re-PTCA P-value 1e-PTCA re-PTCA P-value
ns46a ns40a ns30a ns31 ns16 ns9a
Anxietyb (score 08) 26% 43% 0.11 30% 31% 0.30 31% 67% 0.09
Depressionb (score 08) 15% 28% 0.30 10% 26% 0.11 25% 33% 0.67
Well-beingc (score -14) 18% 23% 0.16 17% 23% 0.61 19% 25% 1.0
Disabilityc (score )33) 47% 36% 0.32 48% 32% 0.21 44% 50% 0.77
Despondencyc (score )21) 13% 31% 0.05 7% 29% 0.03 25% 38% 0.65
Social inhibitionc (score )14) 27% 23% 0.71 17% 16% 0.91 44% 50% 1.0
VAS median 2.6 4.0 0.30 2.2 2.6 0.41 3.3 5.9 0.25
a
HPPQ analysis is based on 84 questionnaires because two respondents, one male (1e -PTCA) and one female (re-PTCA), did not entirely
complete the questionnaire.
b
HADS.
c
HPPQ.

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 M.J. Lenzen et al. / European Journal of Cardiovascular Nursing 1 (2002) 195201
concluded, prior to the diagnosis and recommendation
of the cardiologist that a repeat intervention was neces-
sary. It is noteworthy that the respondents did not link
these symptoms to a failure of the previous treatment
but rather to the progression of their disease. The
respondents had different views on the need for infor-
mation prior to the repeated procedure. Some continued
accumulating information. Others, however, felt they did
not need any information, as one explained by saying:
I know what it is all about. It was regarded senseless
to receive information they already knew. Another aspect
was the timing of information. Some patients experi-
enced negative effects when information was provided
too soon whereas other patients experienced negative
effects when information was provided too late. Descrip-
tions of both procedural and sensory information were
seen in the interviews. The element that was considered
most important was procedural information, as one
patient said: make clear to me beforehand what is going
on. The third theme recognized in the interviews was
labelled experience. The experience with the fifth
procedure played a role in how patients viewed a repeat
intervention. For example the first-time you think,
should I do it or notnow I dont have to think about
it. As none of the 5 respondents had complications
after their previous procedure, no link was established
between complications and their influence on how
patients prepared themselves for the repeat intervention.
The last theme considered future prospects. The respon-
dents indicated a positive view of their future. They
looked forward to a period once again without any
symptoms although they were aware of the fact that the
symptoms could return: but once its finishedyou
really are your old self again, and: I cant expect the
doctor to promise that Ill be fine for the next 5 years.
4. Discussion
This is the first study that attempts to ascertain
whether patients undergoing a repeat PTCA benefit from
the same preparatory information as first-time PTCA
patients. In order to determine if different preparation is
indicated, anxiety and well-being were compared in
patients with a first-time and repeat PTCA. A trend is
seen towards a worse condition in the re-PTCA group
with respect to anxiety and well-being. The only statis-
tically significant difference is seen in patients who
scored above the clinical implication cut-off point of the
HPPQ sub-scale despondency, which measures emotion-
al stress. This study also reveals a clear difference
between genders. Females score less favourably than
males on all measures. Moerman et al. w18x also found
that females scored higher then males on the anxiety
scale when facing a repeat (surgical) intervention.
The absence of significant differences, however, does
not mean that the results are not important w25x. A non-
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199
significant difference can be associated with a clinically
relevant indication, as was seen in this study. A clear
trend is seen in all psychological measures of anxiety
and well-being indicative of a less favourable state in
the repeat group compared to the first-time group. In
the literature, poor scores on psychological question-
naires are always associated with slower recovery w4x,
more post-operative complications w8x and the occur-
rence of cardiac ischemia and ventricular rhythm disor-
ders w29x as well as a higher mortality rate w26x in
patients with heart disease.
The fact that re-PTCA patients score less favourably
may not only be attributed to their previous experience
with this procedure but also to the period following the
procedure. Analysis of interviews with 5 patients in the
re-PTCA group reveals that they are keenly aware of
the fact that the symptoms could return. The previous
procedure was not able to prevent the recurrence of
symptoms. This underlines the importance of future
expectations.
The less favourable scores may also be related to
recurrent feelings of disability, as re-PTCA patients
experienced again limitations in their daily activities due
to anginal symptoms. In contrast, when comparing the
results of the present study with the outcomes of HPPQ
one year after a PTCA w30x, which are considerably
better on well-being and feelings of disability. Other
explanations could be the gravity of symptoms (only
13% of the respondents in Domburgs study had symp-
toms, compared to all in the present study) and the fact
that they are not facing an intervention soon, which is
considered a stressful fact w8,13,24x.
As mentioned in Section 1, the self-regulation theory
proposed by Leventhal and Johnson w7x was used as the
theoretical framework of this study. This theory places
great importance on procedural and sensory information
w3,5,9x. In the hospital where this study took place,
existing protocols specify the delivery of this type of
information. Subsequently, it was assumed that both
procedural and sensory information was given to the
respondents. Sensory information leads to the formation
of a mental image of the procedure, which has three
effects: detachment from emotional memories, recogni-
tion and habituation. These effects are believed to reduce
negative feelings, resulting in less anxious patients
w13,30x. The interviews show that some respondents
possess accurate procedural and sensory information.
However, it is questionable if this type of information
is equally effective for both groups of patients. Despite
the repetition of procedural and sensory information,
patients in the re-PTCA group are still more anxious
and exhibit a lower sense of well-being than patients
undergoing their first PTCA. The respondents who were
interviewed indicate that they know what they are
facing. It could be concluded that these patients, with
their knowledge (experience), exhibited recognition and
200 M.J. Lenzen et al. / European Journal of Cardiovascular Nursing 1 (2002) 195201
habituation, two of the above-mentioned three effects.
The third effect, detachment from emotional (negative)
memories, is related to a previous medical procedure
and is the topic of discussion. This detachment is based
on the differences between a previous procedure and the
following procedure w13x. Patients undergoing a repeat
intervention will often receive the same information that
they received the first-time. The question is: how does
this recall of procedural and sensory information affect
the emotional state of patients before the repeat proce-
dure? The possibility that repeat information may awak-
en (negative) emotional memories instead of help the
patient to forget them cannot be ruled out. These
findings support the need for further investigation con-
cerning how to prepare patients for a repeat intervention.
For example, should these patients be given the change
to ask their own questions? This would facilitate the
provision of information based on a dialogue with the
patient instead of rigid adherence to standard informa-
tion. Maybe there is a greater need for emotional
support than for information concerning a procedure
with which they are already familiar. Furthermore,
coaching may be appropriate in this context. Coaching
is a continuous process of supporting, stimulating and
advising patients to help them meet the goals, that they
have helped to set. These questions can best be explored
with a qualitative descriptive investigation.
In addition to sensory information, the theory of
Leventhal and Johnson w7x focuses on the activation of
the coping mechanism and on coping instructions. The
interviews demonstrate that respondents with recurring
symptoms already consider the necessity of a repeat
intervention. However, this might have activated their
coping mechanism in an early stage (i.e. thinking that a
repeat PTCA is needed), these patients did not prove to
be less anxious. Also the question arises, is self-regula-
tion theory w7x the appropriate approach to use with
patients undergoing a repeat procedure? The theory does
not explain how to deal with patients from the moment
their symptoms return, how to deal with the fact that
the information is known to the patients or how to deal
with the patients after the procedure. The interviews
made it clear that patients have different needs with
respect to seeking out information. This is consistent
with the reviewed literature, which refers frequently to
the coping style of the patient w13,30x. The central issue
is rather than the type of information that is provided
the way in which a person copes with a threatening
situation, regardless of previous interventions.
4.1. Limitations
Due to the fact that no power analysis was performed,
the possibility that the sample (ns86) was too small to
yield significant differences cannot be dismissed. The
sample size was based on the number of variables and
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the practicalities associated with conducting the study.
Another limiting factor is the assumption that all patients
were prepared in more or less the same way. The fact
that a hospital protocol specifies the provision of pre-
paratory information does not mean that all patients
received the same information. The last possible limi-
tation concerns the instruments. The simple fact that
patients had little trouble completing the questionnaires
and that these questionnaires have been judged to be
valid and reliable in other studies are not enough to
guarantee that the questionnaires are equally sensitive
for the purpose and questions of this study. The HPPQ
with its three possible responses (correcty?yincorrect)
might not have been sensitive enough to demonstrate
clear differences in this study, as it might be very
tempting to check ?. In contrast, the HADS instrument
offers four possible responses, which encourages patients
to make a choice. The previously described factors need
to be addressed in future investigations.
5. Conclusion
However, there are no statistically significant differ-
ences between the two groups, a trend is seen towards
a worse condition in the re-PTCA group with respect to
anxiety and well-being. It cannot be concluded however,
that undergoing a repeat intervention (re-PTCA) causes
more anxiety. The less favourable score of the re-PTCA
patients may be attributed to the return of the symptoms
and new feelings of disability, instead of the procedure
itself. Besides the above-mentioned difference between
the two groups, both groups of patients show a clear
discrepancy between desired and actual ability. The
interviews indicate that these patients know what they
are facing and underline the importance of a positive
view of the future. These patients are aware that symp-
toms can return, even though the results of the previous
and current treatment can be considered to be successful.
In other words, they know that they are not cured.
Finally, it should be noted that research does not only
help explain the rationale behind certain actions, such
as giving preparatory information in the context of the
theory by Leventhal and Johnson w7x. Research also
gives insight into which actions lead to the desired effect
and which do not. In this study, one of the desired
effects of preparatory information, namely reduction in
anxiety is less pronounced in the re-PTCA group of
patients. Clearly, additional or different actions are
needed to reduce anxiety in patients undergoing a repeat
intervention. Further research is required.
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