Experiencing a cardiac event or being diagnosed with a cardiac condition can have a profound psychological effect on patients. Not only are acute cardiac events followed by emotional distress, but there are also important psychological consequences for patients with an implantable cardioverter-defibrillator (ICD), both post-surgery and in daily life. Chronic heart failure and depression commonly co-exist, and a person's personality even appears to play a role in cardiovascular disease.
This issue's column will outline some of the psychological effects of cardiac conditions and events, and how nurses might best support patients. My next column will delve deeper into depression in heart failure, and the role of personality in heart and circulatory diseases.
Cardiac distress
Unfortunately, rates of depression and anxiety have been reported to be 20–30% after a cardiac event, and rates of post-traumatic stress disorder and suicide are also elevated (Jackson et al, 2018a). People with cardiac conditions who are distressed have been found to be less adherent to lifestyle recommendations, are more likely to smoke or relapse after quitting, consume more dietary fat and engage in less physical activity (Jackson et al, 2018a). Unsurprisingly, cardiac patients who are depressed or anxious also face a higher risk of hospital readmission, recurrent cardiac events, and premature mortality (Jackson et al, 2018a).
It is therefore essential for nurses receiving admissions of patients with cardiac conditions to be aware of these elevated rates of depression and anxiety, and understand how crucial addressing this is to a patient's overall recovery. Offering compassion, empathy and support, as well as providing appropriate referrals and signposting to relevant local services, can help patients to feel less alone on their journey.
Jackson et al (2018a) point out that cardiac distress should be seen as a persistent negative emotional state rather than transient (a more transient state is referred to as the ‘cardiac blues’). They note that emotional aspects of this distress include worrying about, for example, not being able to return to work, one's financial situation, dying and what will happen to family members if this happens, how to manage one's condition, suffering another cardiac event or a worsening of one's condition, becoming a burden on others and what will happen in the future (Jackson et al, 2018a).
Other feelings may also be present such as sadness, helplessness, irritability, anger, loneliness, dissatisfaction with changes forced upon the person as a result of his or her condition, emotional exhaustion, and a general sense of emptiness or lacking a purpose or meaning in life. They may feel isolated and lonely, and avoid social situations or activities and places that make their heart beat faster or that remind them of their heart event (Jackson et al, 2018a).
ICD surgery
Another factor that can add to the psychological complexity of a cardiac patient's experience is the implantation of a cardioverter defibrillator. On the one hand, an ICD reduces a person's risk of sudden death by terminating episodes of ventricular tachycardia or fibrillation. On the other hand, many of these patients also experience a compromised quality of life, as well as anxiety and depression (Jackson and Murphy, 2017). Receiving a shock from one's device, which can be appropriate and sometimes inappropriate, can lead to anxiety and also a decrease in quality of life (Jackson and Murphy, 2017).
One comparative study revealed that patients who had received a shock from their ICD had a prevalence rate of 37.5% of anxiety disorders, compared with a rate of 8% in those who had not received a shock (Jacq et al, 2009). Interestingly, psychological wellbeing and quality of life have also been reported to be better in those who have had an ICD fitted at 3 and 12 months post-surgery, than those who have not, but worse in those who have an ICD and have received a shock (Jackson and Murphy, 2017).
Therefore, being aware of patients who have had an ICD fitted, how recently and whether they have received any shocks will be important to the person's care. Spouses of patients with an ICD have also been shown to have high anxiety (Jackson and Murphy, 2017).
Personality type, as well as social support and gender, play a role, because women are more likely to receive ICD shocks and experience anxiety (Jackson et al, 2018b), while a type D personality (Denollet, 2005) is associated with impaired quality of life and greater risk of mortality.
Role of the nurse
An important role of the nurse when caring for a patient with a cardiac condition is to find out how the person is coping with their condition, whether they appear to have social support, and whether they take advantage of cardiac rehabilitation services. Such services, which are largely underutilised, can help to not only reduce risk of a further heart attack or death by 25-30%, but also significantly improve a person's quality of life and provide much needed emotional and psychological support (Jackson and Murphy, 2017; British Heart Foundation, 2018).