As I have written here earlier:
“There are few life events more stressful, in my considered opinion, than surviving a heart attack.
“Not only is the actual cardiac event a traumatic and overwhelming experience in itself, but what very few cardiologists tell us before they boot us out the hospital door is how debilitating the day-to-day angst about every subsequent bubble and twinge can actually be.
“I can recall, for example, feeling virtually paralyzed with fear over unexpected chest pains following my heart attack (symptoms, I later learned from my cardiac nurse, that are often called “stretching pain” – common in coronary arteries with recently implanted coronary stents). These frightening symptoms can last for weeks.”
Yet even among those survivors who don’t experience distressing symptoms like these, the severe emotional blow that lingers after a cardiac event can be shockingly debilitating to many.
That’s why there is actually no such thing in reality as a “small” heart attack.
Now, for a straightforward clinical example of rating a cardiac event, California cardiologist Dr. Daniel Lee Kulick illustrates how doctors might assess the severity of a heart attack – usually to help predict how much time is required for the dead heart muscle that’s been deprived of oxygenated blood flow during the attack to complete its scarring process:
“After a small heart attack (little damage to heart muscle), patients usually can resume normal activities after two weeks. A moderate heart attack (moderate damage to heart muscle) requires limited, gradually increasing activity for up to four weeks, while a large heart attack (much damage to heart muscle) may result in a recovery period of six weeks or longer.”
This fairly straightforward and practical prognostication of a patient’s back-to-work timeline, however, completely misses the boat when it comes to acknowledging the profound psychosocial impact of surviving a heart attack – no matter how much physical damage to the heart muscle has occurred.
A heart attack is simply so unlike any other health issue.
Briefly, physicians assess the seriousness of any heart attack based on the amount of heart muscle that is permanently damaged by a sudden lack of blood flow to that muscle. If you’re a physician, there are two main types of heart attacks you will look for: STEMI and NSTEMI.
STEMI means an ST-segment elevation myocardial infarction in which a coronary artery is completely blocked and part of the heart muscle is left without an oxygenated blood supply. “ST segment elevation” refers to a heart rate pattern that shows up on an electrocardiogram (EKG).
NSTEMI (Non-ST segment elevation myocardial infarction) does not show a change in this specific ST segment elevation on an EKG, and generally results in less damage to the patient’s heart muscle.
The location of the blockage, the length of time that blood flow is blocked, and the amount of heart muscle damage that occurs all determine the type of heart attack that physicians will describe.
But both this specific focus on an EKG reading and the lack of medical attention to the profound psychological impact of any cardiac event mean significant factors are often overlooked.
As Dr. Gilles Dupuis of the Université du Québec and the Montreal Heart Institute reported in the May 2010 issue of the Canadian Journal of Cardiology, post-traumatic stress disorder following heart attack is an under-diagnosed and often unrecognized phenomenon that can actually put survivors at risk of another attack.There are, of course, individual differences in recovery depending on a broad range of factors.
And recuperation from a heart attack or any traumatic cardiac condition cannot be compared to that experienced in the world of acute medicine where recovery from surgery or other treatments can often be realistically plotted, barring unforeseen complications.
When I went through four months of cardiac rehabilitation, a man in our group bragged to the rest of us one day that he was now golfing three times a week. I felt both impressed and dismayed. He had undergone triple bypass surgery about the same time as my own heart attack happened. I had not had bypass surgery, yet was barely able to function from day to day.
How could he possibly be happily playing golf already?
One of the differences may have been that he had NOT actually experienced a myocardial infarction (heart attack) that could damage his heart muscle; his surgery had been done as a scheduled, non-emergency, elective procedure related to stable angina symptoms.
Meanwhile, I had survived a misdiagnosed heart attack that then resulted in ongoing cardiac issues including Inoperable Coronary Microvascular Disease.
Some heart patients, on the other hand, experience massive heart attacks, cardiac arrest or other life-threatening events and yet seem to proceed calmly through an uneventful recovery.
Overall, doctors have dismissed the unique mental health issues of heart patients for far too long. See also: When Are Cardiologists Going to Start Talking About Depression?
An Israeli study(1) out of Tel Aviv University’s Sackler Faculty of Medicine, for example, examined the association between depressive symptoms in heart attack patients and subsequent hospital admissions more than a decade after the initial attack. The January 2012 study’s results were troubling:
“Heart attack patients who suffer mental health issues as a result of the attack are more likely to be re-admitted for cardiac events and chest pains in the future, and have 14 percent more days of hospitalization than their counterparts.”
Unlike longterm clinical depression, post-heart attack depression is often called “situational depression”, or “stress response syndrome”, and what mental health professionals call an adjustment disorder that can strike following a traumatic life event as we struggle to make sense of something that makes no sense.
Patients who are struggling emotionally after the trauma of a heart attack can also be far less likely to successfully make post-op lifestyle changes like regular exercise, smoking cessation, stress management or heart-healthy eating. In fact, the Israeli researchers found that patients who suffer depression following a heart attack were:
- 20% less likely to be physically active
- 26% less likely to participate in a cardiac rehabilitation program
- 25% less likely to quit smoking
So it can become an endless vicious circle loop of:
“Feel bad→ Don’t exercise→ Keep smoking→ Poor eating choices→ Feel bad!”
How much social support you have while you’re recuperating can also affect quality-of-life outcomes. For example, the commonly-used social support assessment tool called ESSI (ENRICHD Social Support Instrument) can assess those people at risk for poor social supports by asking patients to answer seven questions before they’re discharged from hospital, including:
“Is there someone available to whom you can count on to listen to you when you need to talk?”
- “Is there someone available to help with daily chores?”
As the Israeli researchers concluded:
“The message is that doctors cannot ignore psychological factors in patients who have had a heart attack. Patients who exhibit signs of depression need to be followed more closely, and may need extra help in following lifestyle recommendations.”
(1) Vicki Myers et al. “Post-myocardial infarction depression: Increased hospital admissions and reduced adoption of secondary prevention measures — A longitudinal study.” Journal of Psychosomatic Research, Volume 72, Issue 1, January 2012, Pages 5-10.
Q: Have you been surprised by psychological fallout after a serious diagnosis?
- The New Country Called Heart Disease
- Chest Pain of Angina Comes in Four Flavours
- Squishing, Burning and Implanting Your Heart Troubles Away
- 10 Non-Drug Ways to Treat Depression in Heart Patients
- How We Adapt After a Heart Attack May Depend on What We Believe This Diagnosis Means
- “What Was That?” A Poem for Heart Attack Survivors
- Women’s Heart Pain is Both Physical and Emotional
- Why Hearing the Diagnosis Can Hurt Worse Than the Heart Attack
- Depressed? Who, Me? Myths and Facts about Depression Following a Heart Attack
- “I’m Not Depressed!” – and Other Ways We Deny the Stigma of Mental Illness After a Heart Attack
- Should You Take Antidepressants – And If So, Which One?
- Is it Post-Heart Attack Depression – or Just Feeling Sad?
- Post-Traumatic Stress Disorder: Not Just For Soldiers Anymore
- Women Heart Attack Survivors May Be as Psychologically Traumatized as Victims of Violence
- Why Aren’t Women Heart Attack Survivors Showing Up for Cardiac Rehab?
- Handling the Homecoming Blues