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 “stretch 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 – or simply how much time this patient should be off work:
“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 dispassionate prognostication of a patient’s back-to-work timeline, however, 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 – either due to a blockage or spasm in the coronary artery feeding that muscle. If you’re a physician, there are two main types of heart attacks you will look for: STEMI and NSTEMI (or Non-STEMI).
By the way, a growing number of cardiologists support both revised names and definitions for heart attacks; read more about why U.S. cardiologists like Dr. Stephen Smith, Dr. Pendrell Meyers, Dr. Ken Grauer and many others are supporting this movement here.
But until those revisions happen, here’s how these two cardiac events are currently described:
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) shows a depressed ST segment on an EKG. It is generally thought to be a less serious heart attack.
IMPORTANT NOTE: According to Emory University researchers Dr. Tina Varghese (internal medicine) and Dr. Nanette Wenger (cardiology), women diagnosed with NSTEMI are less likely than their male counterparts to receive guideline-recommended treatments and interventions:
“One evident contributor to this gender disparity is the predominance of middle-aged men in cardiac studies on cardiovascular disease; women are significantly under-represented in cardiac research. The 5-year risk of death from NSTEMI for women is 42% (versus 29% in men).”
The specific location of a coronary artery blockage, the length of time that blood flow is blocked, and the amount of heart muscle damage that occurs because of that reduced blood flow all help to determine the type of heart attack that physicians will describe.
But both this specific focus on accurately interpreting an EKG reading and the lack of medical attention to the profound psychological impact of any cardiac event can mean significant factors are often overlooked.
As Dr. Gilles Dupuis of the Université du Québec and the Montreal Heart Institute reported in 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 three 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 damaged his heart muscle; his surgery had been done as a scheduled, non-emergency, elective procedure related to the stable angina symptoms he’d reported to his doctor, and the subsequent cardiac tests that showed one or more coronary arteries had blockages in them – not enough to cause a heart attack or serious heart muscle damage, but enough to convince his cardiologist that open heart surgery was necessary to “save his life”. By the way, many patients will describe their cardiologists as being “life savers” – even when death was hardly imminent.
Meanwhile, I had survived a misdiagnosed heart attack that then resulted in ongoing cardiac issues including heart muscle damage and 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, 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 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-discharge lifestyle changes like regular exercise, smoking cessation, stress management or heart-healthy eating. In fact, the Israeli researchers found that patients who suffer new-onset 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.(2) The first six use a 5-point LiKert scale numbered 1 (strongly disagree) to 5 (strongly agree). The seventh item is a yes/no question, scored 4 for yes and 2 for no. Total scores range from 8 to 34. Cardiologist should be aware of how much social support you’ll realistically have after you get home – but most are not. If your hospital has a cardiac social worker on staff, request an appointment before you’re discharged home to discuss your own ESSI scores.
The seven ESSI items are:
- Is there someone available to you whom you can count on to listen to you when you need to talk?
- Is there someone available to you to give you good advice about a problem?
- Is there someone available to you who shows you love and affection?
- Is there someone available to help you with daily chores?
- Can you count on anyone to provide you with emotional support (talking over problems or helping you make a difficult decision)?
- Do you have as much contact as you would like with someone you feel close to, someone in whom you can trust and confide?
- Are you currently married or living with a partner?
(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.
2. Mitchell, Pamela H., et al. 2003. “A Short Social Support Measure for Patients Recovering from Myocardial Infarction.” Journal of Cardiopulmonary Rehabilitation 23 (6). Ovid Technologies (Wolters Kluwer Health):398–403.
Q : Have you been surprised by psychological fallout after a serious diagnosis?
NOTE FROM CAROLYN: I wrote about surviving a misdiagnosed widow maker heart attack – and much more! – in my book, A Woman’s Guide to Living with Heart Disease. You can ask for it at your local bookshop or library, or order it online (paperback, hardcover or e-book) at Amazon – or order directly from my publisher, Johns Hopkins University Press (use the JHUP code HTWN to save 30% off the list price).