PTSD, stress and anxiety after a major cardiac event

Having a major cardiac event can be a stressful, life changing occurrence. Often, the psychological impacts of having a heart attack (myocardial infarction) are underestimated and can be long lasting. In fact, there is evidence to suggest that these that the emotional stressors that occur post-MI are consistent with symptoms of post traumatic stress disorder. PTSD has been shown to be associated with higher rates of recurrent coronary events and overall increased mortality in diagnosed patients.

The New York Times published an article highlighting a meta analysis of numerous studies looking at PTSD in post-MI patients. In the analysis 1 in 8 patients developed PTSD type symptoms. The study went on to demonstrate an association between PTSD and death from recurrent CV events. This is not insignificant.

Today, MI care in most places in the US is state of the art. Patients are surviving catastrophic cardiac events due to advanced technologies and more immediate response times. The population of MI survivors is becoming much larger than seen in previous eras–thus leaving more patients at risk for PTSD and subsequent events. Many of these “survivors” go on to have implantable cardioverter defibrillators (ICDs) placed which also prolong life. Certainly the combination of post-MI PTSD and the emotional impact of ICD implantation can significantly contribute to patient stress and anxiety.

We, as providers of CV care must be more aware of the psychological impact that CV events and procedures have on our patients. If we are able to intervene early in the peri and post-MI periods, we may be able to prevent the development of PTSD and anxiety disorders. Psychological evaluation and counselling should be a part of routine post-MI care (just as nutritional consults and administration of beta blockers and ACE inhibitors are).

In some cases, drug therapy with SSRI antidepressants, and short term anxiolytic use may be indicated. Certainly, spending time discussing the events with your patients will help them process the trauma. The power of discussing and working through the fear and uncertainty that can accompany a major CV event cannot be underestimated. With appropriate counselling, we can help our patients develop positive coping mechanisms that allow them to continue on living in a more adaptive way.

Much has been written about the psychosocial impacts of ICD therapy. A lot of the same interventions can be applied in the post-MI patient . I would suggest developing a “chest pain plan” similar to the “ICD shock plan” I had discussed previously. I would suggest the following for a patient initiated and maintained plan. It is important that the patient execute this plan. By crafting the plan and collecting the data, the patient feels empowered. Empowerment helps us deal with situations that are often beyond our control such as a major cardiac event.

  1. The patient should collect all data and have it readily accessible and in one place. Make the data also available to a spouse, significant other or other family member. This may include Dr names and numbers, a brief CV medical history including the dates of prior events and technical information such as location and identification of prior coronary stents, bypass grafts, and (certainly if appropriate) ICD type and serial numbers. With data comes power and preparedness. This empowers patients.
  2. Help the patient understand the symptoms of concern. Make sure that the patient has a checklist of symptoms and how to handle them. This may be as simple as “if you have chest pain take a nitroglycerin tablet. If you have to take 3 tabs, call EMS.” A plan of action helps simplify the situation. Understanding and knowing how to respond gives patients a sense of control. This empowers patients.
  3. Make sure the patient understands that they are not alone. Support groups such as those developed for ICD patients are certainly applicable to all patients who have survived a major CV event. Feelings of isolation and hopelessness can drive depression and contribute to PTSD. Knowing that there are other “brothers in arms” in the fight against CV disease is often comforting. This empowers patients.

So, we know that traumatic events can have life changing psychological impacts. Surviving an MI is a major psychological stressor. We cannot underestimate the negative impact that PTSD, depression and anxiety can have on long term survival after a major CV event. Take time to assess the emotional well being of your cardiac patient. Empower patients with knowledge and give them back some control. Remember, by spending a few extra minutes assessing the emotional impact we can intervene early and help to prevent PTSD and future cardiac events.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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