“Discharge from the hospital is a highly difficult time for both patients and families, who are often under-supported. Our study found that the levels of the stress hormone cortisol in heart attack patients increased sharply after hospital discharge – and they can stay elevated for months.”
The study that Dr. Doreen Rabi described to me may help to answer the question that so many of my Heart Sisters readers have been asking for years: Why do I feel worse after my heart attack before I start to feel better? . . .
I asked myself the same question after being discharged from the hospital following my own heart attack. Shouldn’t I feel relieved and grateful now because the blocked coronary artery that caused my heart attack had been magically re-vascularized? Wasn’t I “fixed”?
Instead, I felt frail and scared. Every twinge in my chest left me reeling: Is this something? Is it nothing? Should I call 911? I became convinced I would die in my sleep. In fact, every night, week after week, I silently tidied the apartment before bedtime so that when my corpse was found the next morning, at least it would be found in a nice clean place.
I was a wreck. And I knew that I’d already put my family and close friends through so much worry. I didn’t want any of them to worry even more about me, so at the same time I was internally screaming, I was also trying to practice happy-face smiling when in their presence. I didn’t know it at the time, but this not-uncommon patient decision was what psychologists call emotional labour.
And it’s not good for us!
Dr. Rabi’s initial message to me was a Twitter response to a blog post I’d written about how the medical profession has abandoned the historically important concept of convalescence (that’s the period of recuperation care between the time we leave the hospital and the time we are truly recovered). She agreed that this post-discharge period can be fraught with unexpected issues, even for heart patients whose cardiac events have been successfully treated. See also: The hospital discharge race: is sooner always better?
Dr. Rabi is Head of the University of Calgary’s Division of Endocrinology & Metabolism, and a full professor in the Departments of Medicine, Community Health and Cardiac Sciences. Even more importantly to me, Dr. R. has a keen interest in women’s heart health specifically. (1)
In the study she mentioned, published in the European Journal of Preventive Cardiology,(2) Dr. Rabi and her colleagues evaluated repeat samples for the stress hormone cortisol in 309 heart patients aged 18–55 years, starting within 48 hours of their hospital admission. Patients were also followed up one, six, and 12 months after their cardiac events. This was “one of few studies that looked at post-hospital discharge levels” of this stress hormone.
Cortisol is an important hormone produced in our adrenal glands. But too much of it can wreak havoc on the body, causing an increase in heart rate, blood pressure and blood glucose as part of our fight-or-flight response, along with other distressing symptoms.
The cortisol study’s findings were striking: about one-third of these heart patients showed “persistently elevated cortisol levels, which are associated with the type of inflammation that contributes to coronary artery disease.”
You might imagine that the most stress-inducing part of any cardiac event would actually be during the middle of a heart attack. So I asked Dr. Rabi why our cortisol levels tend to increase sharply AFTER we’re already discharged from the hospital, and here’s how she answered:
“I can only speculate here, but my sense is that there are two things at play.
“The first is that having a cardiac event is inherently frightening. The care received by most patients in acute coronary care units is excellent and intensive. People feel well-monitored and supported. Being surrounded by people who manage heart disease every day provides some sense of reassurance and safety, so leaving that safe environment to be on your own can be daunting.
“The second piece we need to acknowledge is that a cardiac event like a heart attack introduces a huge number of changes to one’s life, including restrictions on activities, new medications and often new dependencies. These are all uncomfortable changes that are often not fully realized by the patient or their family members – until they are back at home and feel the acute tension between who they were before this new diagnosis and the new person they are now.”
Dr. Rabi added:
“This study suggests that the transition for some patients (particularly those with a history of smoking, peripheral vascular disease and those with chronically elevated blood glucose levels) is a prolonged stress.”
She offered one specific challenge in this area: in general, our baseline cortisol test results are not often available.
“This is important: people who experience chronic stress may have persistently elevated cortisol, and so may have a blunted response to extreme stress – like a heart attack.”
She also cited previous studies (for example, one by Dr. Colleen Norris and her colleagues at the University of Alberta) that identified a difference between men and women who had undergone cardiac catheterizations: women tend to have higher levels of this stress hormone than their male counterparts do. (3)
A 2016 research study Dr. Rabi mentioned (Dr. Petr Kala and colleagues from the Czech Republic) tracked symptoms of depression and anxiety in heart patients from 24 hours post-cardiac event to one year post-event.(4)
“These researchers found that symptoms were highest immediately after a cardiac event, and were the lowest at the time of discharge. Symptoms then increased again once patients were back home, hitting a second peak at six months.”
Coincidentally, and echoing the findings of the Czech study, six months after surviving a misdiagnosed heart attack, my GP would have said that I had “recovered” from that cardiac event, but my troubles were not over. For example:
- my ongoing cardiac symptoms had been subsequently diagnosed as coronary microvascular disease
- I had failed my half-time return-to-work trial
- I lost my job
- I’d been forced to apply for longterm disability benefits
- I was crying for long periods every day
- I had to literally beg my (now former) GP for a referral to see a psychotherapist.
Dr. Rabi suggests that women experience more chronic stress that impairs our physiology, and then we experience more anxiety, depression, lower quality of life, and more isolation compared to our male counterparts, post-cardiac event. She adds:
“What we likely need to further investigate is not whether the high cortisol is a problem, but whether the chronic stress that prevents women from mounting a normal stress response is the problem.”
Take care. Stay safe. . .
1. Pelletier R, Khan NA, Rabi DM, Cox J, et al. “Sex Versus Gender-Related Characteristics: Which Predicts Outcome After Acute Coronary Syndrome in the Young?” Journal of the American College of Cardiology. 2016; 67(2):127-135.
2. Tang AR, Rabi DM, Lavoie KL, Bacon SL, Pilote L, Kline GA. “Prolonged hypothalamic-pituitary-adrenal axis activation after acute coronary syndrome in the GENESIS-PRAXY cohort.” European Journal of Preventive Cardiology. 2018; 25(1):65-72.
3. Norris CM et al. “Gender as a determinant of responses to a self-screening questionnaire on anxiety and depression by patients with coronary artery disease.” Gend Med. 2009; 6(3):479-487.
4. Kala P et al. “Depression and Anxiety after Acute Myocardial Infarction Treated by Primary PCI.” PLoS One. April 2016; 11(4):e0152367.
Image: Goran Horvat, Pixabay
A big hug and a sincere “Thank you!” to Dr. Doreen for taking time out of her extremely busy life to answer my questions for this article.
Q: Did you feel worse before you started feeling better after your cardiac event?
NOTE FROM CAROLYN: I wrote much more about becoming a patient in my book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University Press, 2017). You can find this book:
- at your nearest library branch
- at all bookstores (please support your local independent bookshops)
- order it online (paperback, hardcover or e-book) at Amazon
- order it directly from Johns Hopkins University Press (and use the code HTWN to save 30% off the list price when you order)
– You can watch Dr. Doreen Rabi in the powerful and short (22 minutes) documentary film A Typical Heart. She’s one of the eight medical experts who joined seven heart patients (including me) interviewed for this film about “the deadly disparity in diagnosis, treatment and outcomes between male and female heart patients”.