The paper presents the principal psychological problems in patients following myocardial
infarction. Particular emphasis has been placed on anxiety and depression following myocardial
infarction and behavioural patterns adversely affecting health. A proposal of actions
during cardiac rehabilitation has been presented in accordance with the severity of psychological
problems encountered in the patients. (Cardiol J 2010; 17, 3: 319-324

Kowalska, Monika

Mierzyńska, Anna

Piotrowicz, Ryszard

Stepnowska, Monika

English

Via Medica Journals

319www.cardiologyjournal.orgHOW TO DOCardiology Journal2010, Vol. 17, No. 3, pp. 319–324Copyright © 2010 Via MedicaISSN 1897–5593Address for correspondence: Anna Mierzyńska, MA, Department of Cardiac Rehabilitation and Non-Invasive Electrocardiology,Institute of Cardiology, ul. Alpejska 42, 04–628 Warszawa, Poland, e-mail: anna.mierzynska@ikard.plReceived: 19.03.2010 Accepted: 8.04.2010Psychological support for patientsfollowing myocardial infarctionAnna Mierzyńska, Monika Kowalska, Monika Stepnowska, Ryszard PiotrowiczDepartment of Cardiac Rehabilitation and Non-Invasive Electrocardiology,Institute of Cardiology, Warsaw, PolandAbstractThe paper presents the principal psychological problems in patients following myocardialinfarction. Particular emphasis has been placed on anxiety and depression following myocar-dial infarction and behavioural patterns adversely affecting health. A proposal of actionsduring cardiac rehabilitation has been presented in accordance with the severity of psychologi-cal problems encountered in the patients. (Cardiol J 2010; 17, 3: 319–324)Key words: myocardial infarction, psychologicalIntroductionAbnormalities of cardiovascular function (coronaryartery disease caused by atherosclerosis) are referredto as diseases of major public health importance andtheir development and course are strongly related tothe patient’s psychosocial functioning, lifestyle andbehavioral patterns. The high mortality rate, serioushealth consequences and the necessity to introducenumerous changes in everyday functioning after thediagnosis and hospitalization are the reasons why car-diovascular disease is perceived by patients as one ofthe most serious and threatening life experiences.For these reasons the psychological care of car-diac patients is a very important element of treat-ment and should include a wide scope of functionsperformed by the patient, mainly understood as sup-porting the adjustment to the new conditions of lifeassociated with the consequences of becoming ill.We address the issues related to myocardialinfarction and its consequences for the psychologi-cal functioning of the patient.Psychological responses of patientsfollowing myocardial infarctionThe risk factors of myocardial infarction aredivided into several categories with an importantrole being played by psychosocial factors, such aschronic stress, fast-paced life, type A behavioralpattern (TABP), having too many responsibilities,inability to cope, a considerable accumulation of im-portant life events, depression, anxiety and socialisolation.The warning signs are often ignored or mis-interpreted by the patients, which makes the on-set of myocardial infarction a big surprise forthem. Myocardial infarction is associated witha high level of anxiety, the fear of impending deathand deep frustration resulting from the suddenand serious changes in functioning. The feeling ofdanger additionally exacerbates the need forhospitalization and its consequences reach deepinto the future and significantly affect the patient’squality of life (Table 1).320Cardiology Journal 2010, Vol. 17, No. 3www.cardiologyjournal.orgAnxiety reactionsIntense anxiety is often listed as the major psy-chological response to myocardial infarction and isone of the symptoms associated with this condition.Anxiety is described as an unpleasant emotionalstate coincident with the fear of danger and a num-ber of cognitive changes (e.g. impaired concentra-tion, impaired memory, impaired ability of logicalthinking) and somatic changes (e.g. rapid heart rate,dry mouth, agitation). Soon after the cardiovascu-lar event the level of anxiety is elevated in abouttwo thirds of the patients and reaches clinical lev-els in 20–30%.The high level of anxiety observed followingmyocardial infarction should be considered from twoperspectives. On the one hand, it is a response toa condition which reduces the quality of life, while onthe other hand, it coexists with a number of factorsincreasing the risk of reinfarction in the future, asanxiety disorders have been proved to coexist withhypertension, high cholesterol levels, smoking (in-cluding nicotine dependence), alcohol and drugabuse and with obesity [1–3].Some patients cope with anxiety by denying thepresence of the disease and ignoring endangeringsignals. In the first stage following myocardial in-farction this mechanism reduces the level of nega-tive emotions and may positively affect the patient’sfunctioning. In the long run, however, it impedesthe patient’s confrontation with the consequencesof the disease. Such patients are less motivated toundergo treatment and rehabilitation and to com-ply with the doctor’s directions [4]. The likelihoodof medical complications in the future is thereforeincreased.Depressed mood and depressionDepressed mood is a common response tomyocardial infarction. Between 20% and 30% of thepatients hospitalized for myocardial infarction mani-fest mild to severe depressive symptoms. As manyas 60% of patients referred for coronary angiogra-phy show symptoms of depression, which, coupledwith ischemic heart disease, considerably impairstheir functioning, the chances of recovering and theprognosis [5]. Coexistence of depression anda somatic disorder affect the patient’s health toa much greater degree than coexistence of two so-matic disorders [6]. In addition a considerable per-centage of patients following acute myocardial in-farction (38–48%) report a depressive episode short-ly before the infarction [7].Other psychological responsesfollowing myocardial infarctionIn addition to anxiety and depression the psy-chological responses following myocardial infarctionmay include agoraphobia (triggered by catastro-phic thinking), exhaustion, hostility and health-relat-ed sadness, anger, the feeling of surprise and dis-gust [8].Post-myocardial infarction patients may alsoshow a tendency to social withdrawal. Studies indi-cate that one third (31–35%) of patients followingmyocardial infarction show limited participation insocial activities during the first year after infarction.A similar percentage of patients (27–33% of wom-en and 22–28% of men) show a low level of socialanchoring [9] described as participation in formaland informal social groups [10].Psychological functioningfollowing myocardial infarctionThe physical and psychological consequencesof ischemic heart disease contribute to a consi-derable impairment of the quality of life in all dimen-sions, both physical and mental ones [5, 9]. Theexperience of myocardial infarction also affects theability to achieve life goals. The obstacles interfer-ing with the attainment of these life goals are asso-ciated with a higher level of stress and a lowerhealth-related quality of life after hospitalization [11].Gender-related differences are essential tocoping with the consequences of myocardial infar-ction. Men manifest a higher level of anxiety abouttheir health, while women show a more pronouncedtendency to manifest avoidance behaviors [8].The time factor is extremely important in cop-ing with the consequences of ischemic heart dis-ease. Within the first year following myocardial in-farction patients show an increasing effectivenessof coping with the physical consequences [9]. Also,with time, the health-related quality of life increas-es. However, about 20% of the patients show signsof reduced quality of life related to emotional func-Table 1. Psychological responses to experien-cing myocardial infarction.· Anxiety · Sadness· Depressed mood · Anger· Depression · Surprise· Agoraphobia · Disgust· Exhaustion · Social withdrawal• Hostility321Anna Mierzyńska et al., Psychological support for patients following MIwww.cardiologyjournal.orgtioning even 3–5 years after their infarction. Thehigh level of anxiety and stress following myocar-dial infarction coexists with the difficulties to makethe necessary life changes.It is estimated that the highest quality of lifein the first year following myocardial infarction isreported by patients who had the ability to takeadvantage of various forms of social support: chil-dren, partners, friends, grandchildren. Patients whoreceived support from their closest ones at the timeof the illness and strengthened their family rela-tions, reported a better functioning and health-re-lated quality of life during the first year followingmyocardial infarction. In addition, a significant im-provement in the quality of life was also noticed bypatient who completed a full cardiac rehabilitationprogramme and returned to work or other forms ofactivity carried out before the infarction [9]. For thisreason it is very important to strengthen the feel-ing of control over one’s own health, believing inoneself and see the benefits of rehabilitation.Goals of psychological supportfollowing myocardial infarctionPsychological support for patients followingmyocardial infarction is focused on several areas:secondary prevention of ischemic heart disease,support in the adjustment to the disease, to its con-sequences and to its treatment, modification of be-havioral patterns that are harmful for health andreduction of the level of anxiety and stress causedby this experience (Fig. 1).Secondary preventionof ischemic heart diseaseSecondary prevention aims to change the pa-tient’s lifestyle and health habits with the view tominimizing the risk of health deterioration. It in-volves a number of areas of patient activity. Col-laboration of the patient with the psychologist con-centrates on forming a favorable attitude towardsthe disease or forming an adequate image of theFigure 1. A hierarchy of psychological influences on patients following myocardial infarction according to theseverity of psychological problems related to the somatic status and treatment stage.322Cardiology Journal 2010, Vol. 17, No. 3www.cardiologyjournal.orgdisease and of its treatment. The amount of knowl-edge about the disease, its causes, its consequenc-es and expectations regarding treatment outcomesis the cognitive representation of the disease. Thecognitive representation refers to giving the mean-ing to the symptoms of the disease, predicting itscourse, duration and consequences and predictingthe ways in which it can be controlled and treated[12]. Having an adequate knowledge about the dis-ease is essential for behaviors related to treatmentand experience of the cardiac episode. These be-haviours include, among other things, the prompt-ness of decision to call for an ambulance, the pro-pensity to make changes in one’s lifestyle (diet andphysical activity) and the readiness to return towork. An adequate perception of the consequenc-es of the disease and the control over the recoveryprocess contributes to the motivation to complywith the doctor’s directions and completion of a fullcardiac rehabilitation program [13].Reducing the level of anxietyIn the process of providing psychological sup-port to patients following myocardial infarctiona particular emphasis is placed on interventions re-ducing the severity of anxiety symptoms. Patientswith severe symptoms of anxiety and depressionare more prone to look for the causes of their dis-ease in the sphere of mental functioning. This af-fects the possibilities of coping with the conse-quences of myocardial infarction [14]. Studies showthat the severity of anxiety may be the reason whypatients give up participation in prevention and re-habilitation programs [13]. On the other hand, ta-king advantage of psychological support (for instance,in the form of psychoeducation and psychologicalcounseling for the patient and his or her family)considerably reduces the severity of anxiety anddepressive symptoms [15], contributes to increasedmotivation to undergo rehabilitation and increasesthe level of physical activity.Modification of behavioral patternsModifying behavioral patterns is a very impor-tant aspect of work with cardiac patients. Some ofthe important risk factors for ischemic heart diseaseinclude type A behavioral pattern and type D per-sonality.Type A behavioral pattern is characterizedby a readiness to extreme competitiveness in thefight for achievements, the feeling of excessive re-sponsibility, aggressiveness and hostility (usuallyhidden hostility), impatience, excessive excitabilityand constant rush in speaking and behaving (Fig. 2).The mechanisms linking TABP and ische-mic heart disease are of behavioral and pathophysio-logical nature [16]. The behavioral mechanisms in-clude behaviors harmful for health, such as smok-ing, alcohol abuse, and inappropriate diet. The directpathophysiological mechanisms include increasedheart rate, significantly increased blood pressure inresponse to stimuli, elevated cortisol levels andelevated catecholamine levels.Type D personality is characterized by a ten-dency to experience negative emotions in differenttypes of situation along with a propensity to sup-press the expression of emotions and behaviors insocial contacts (Fig. 3). Patients with this type ofpersonality often feel unhappy, tend to worry, areeasy to irritate, have low self-esteem, create dis-tance in social relations and are introvert. Numer-Figure 2. Type A behavioral pattern (TABP).Figure 3. Characteristics of type D personality.323Anna Mierzyńska et al., Psychological support for patients following MIwww.cardiologyjournal.orgous studies suggest a significant effect of type Dpersonality on mortality related to ischemic heartdisease and on the severity of cardiovascular sym-ptoms [17]. Working with automatic negativethoughts and behavioral patterns leading to the sup-pression of the expression of emotions and needsmay positively affect psychosocial functioning andprognosis in patients with ischemic heart disease.Other goals of psychological supportPsychological interventions are also aimed toincrease the possibility of recognizing one’s owndifficulties and coping strategies and to increase theawareness of signals sent by the body, which mayhelp the patient to more rapidly respond to poten-tial health-threatening situations. At the same timethe patient undergoes training of abilities to copewith the physiological symptoms of stress, expressemotions and needs in interpersonal relations, re-duce the level of hostility, the feeling of identity inthe illness (self-picture of a patient). In situationswhere the patient finds it difficult to cease smok-ing, collaboration with the psychologist involvesfighting the tobacco dependence.In order to increase the quality of life at thetime of illness and to achieve positive effects ofcoping with the consequences of myocardial infarc-tion it is important to create or enhance copingbased on confronting one’s current health situation,optimism and belief in oneself and one’s possibili-ties [9]. It is important that the patient learns toreduce the stress by controlling its physiologicalaspects. Studies show that relaxation exercises(progressive relaxation or qigong) improve mentalfunctioning (reduces the level of anxiety and im-proves the self-perceived quality of life) and somaticfunctioning (by reducing blood pressure and heartrate, for instance) [18].ConclusionsPatients following myocardial infarction mayfind it difficult to adjust to their new health situa-tion. These difficulties may take the form of depres-sive or anxiety reactions and impaired social func-tioning. The psychological problems encounteredduring cardiac rehabilitation may considerably in-terfere with recovery and reduce the motivation toundergo treatment and comply with the doctor’sdirections. For this reason it is important that thepatients are provided with psychological support.Getting to know the patient’s individual traits (e.g.personality type, level of anxiety) and his or her lifesituation (e.g. level of social support) helps to se-lect the most effective form of psychological inter-vention. Patients following myocardial infarctionwho are provided with psychological support du-ring and after hospitalization have a higher qualityof life and significantly lower risk of reinfarction inthe future.AcknowledgementsThe author appreciate help of Paweł Baka withpreparation of the authorized English version of themanuscript.The authors do not report any conflict of inte-rest regarding this work.References1. Barger SD, Sydeman SJ. Does generalized anxiety disorder pre-dict coronary heart disease risk factors independently of majordepressive disorder. J Affect Disord, 2005; 88: 87–91.2. Gomez-Caminero A, Blumentals WA, Russo LJ, Brown RR,Castilla-Puentes R. Does panic disorder increase the risk of co-ronary heart disease? A cohort study of a national managed caredatabase. Psychosom Med, 2005; 67: 688–691.3. Patten SB, Liu MF. Anxiety disorders and cardiovascular di-sease determinants in a population sample. Int J Ment Health,(serial online), 2007; 4: 2 (Available from: Academic SearchComplete, Ipswich, MA).4. Levine J, Warrenburg S, Kerns R et al. The role of denial inrecovery from coronary heart disease. Psychosom Med, 1987;49: 109–117.5. Sawicka J, Jurkowska G, Bachórzewska-Gajewska H, Dobrzycki S.Evaluation of the quality of life and frequency of depressivesymptoms In patients with coronary hart disease before plannedcoronarography. Przegl Kardiodiabet, 2008; 3: 23–27.6. Moussavi S, Chatterji S, Verdes E et al. Depression chronicdiseases, and decrements in health: results from the WorldHealth Surveys. Lancet, 2007; 370: 851–858.7. Fiedling R. Cognition, control, and mood during recovery fromAMI. Abstr Int Conf Health Psychol B. P. S. UK 1998.8. Bowman G, Watson R, Trotman-Beasty A. Primary emotions inpatients after myocardial infarction. J Adv Nurs, 2006; 53: 636–645.9. Kristofferzon M-L, Löfmark R, Carlsson M. 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Psychological support for patients following myocardial infarction

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Psychological support for patients following myocardial infarction

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