Monthly Archives: June 2012

PTSD and MI: Worry and Increased Risk of Post MI Death

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.

Last week 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, by Edmondson, et al 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 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 by Dr Sam Sears and by me in other blogs. 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 have 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.

Loneliness and The Elderly: Dying of a Broken Heart

In the last decade, I lost both of my maternal grandparents.  I can remember both of them as vibrant, active and engaged.  However, when my grandfather began to develop significant medical problems and declined cognitively, things really changed.  His medical problems eventually necessitated a move to a skilled nursing facility.  It was at this point that I began to notice a precipitous decline in my grandmother.  She began to become reclusive (she was formerly a good golfer and avid traveller).  She became depressed.  When my grandfather died, she began to develop more medical problems.  Eventually she was admitted to a full time skilled nursing facility.  Her mental capacities dwindled, she stopped participating in any type of rehab and ultimately died in the facility.  We have all heard of spouses that die within a few months of each other and I have always believed that profound loneliness and sadness must follow the loss of a lifelong partner.  I believe that this loneliness certainly played a role in my grandmother’s demise.

Recently, two interesting articles were published in the Archives of Internal Medicine addressing the impact of loneliness and isolation on mortality and cardiovascular disease in the elderly.   In a manuscript by Perissinotto et al, the relationship between loneliness and functional decline/death was examined.  In this cohort, loneliness was significantly associated with a decline in ADL activities, decline in mobility, and increased risk of death.  In a second paper, Udell, et al investigated whether living alone was associated with increased mortality and cardiovascular risk using the REACH registry data.  Living alone was found to be associated with a higher 4 year mortality and cardiovascular death. This association is important.  Nearly 1 in 7 American adults are living alone and this isolation may provide additional stressors such as depression, anxiety and additional economic pressures.  These stressors certainly may contribute to cardiovascular events in susceptible patients.  Moreover, social isolation has been associated with changes in health behavior and access to care among patients.  Patients who live alone may be less likely to seek care for recurrent symptoms and may not be compliant with drug therapy or other medical recommendations without support.

Previous studies have demonstrated similar findings.  A 2012 study in Circulation reported that patients who have had a spouse die suddenly are 20 times more likely to die from a cardiovascular event such as a heart attack in the first 6 weeks surrounding the loss.  Separate studies involving couples in Scotland and in Israel demonstrated that the risk of death among widows or widowers approaches 30-50% in the first 6 months after the death of a spouse.  We can certainly infer that the bereaved were lonely and may have felt socially isolated. 

There is no easy answer to this problem.  Our patients today are sicker and have more limited resources.  Financial pressures are forcing physicians to tackle larger clinic schedules with overall increased workload demands.  But, as providers of health care, we must assess social isolation and loneliness in our patients.  We must identify “at risk” patients and make attempts at intervention.  Since these studies suggest that living alone is an independent prognostic factor for mortality and CV disease, clinicians must work to counsel their patients about seeking appropriate medical attention when needed and, in appropriate cases, refer patients to programs with psychological intervention.  Many of these patients have no families, no adult children and no support group.  In these cases, we must do our best to fill in the gaps (yes, all in a busy office full of patients).  Healthcare costs in the US continue to skyrocket and there are no easy fixes in the works.  I believe that a simple, although potentially time consuming, intervention such as talking with lonely and socially isolated patients when they are in the office for a visit, is a low cost preventative measure.  By taking time to hold a lonely patient’s hand, we may potentially make a positive impact. Data such as those presented in the Archives this month certainly point out the risks of loneliness and suggest that patients without social support in place do very poorly and develop significant cardiovascular illness.

My grandparents lived full, rich lives.  They had family and friends who loved and cared for them.  As a couple they had many many good times together.  However, one cannot underestimate the impact of losing a spouse of 50 years.  The impact of living alone after sharing a household for nearly one’s entire adult life is powerful indeed.  Embrace those whom you love.  Let them know you care.  Hold your patient’s hand.  And don’t ever forget that people can truly die of a broken heart.

The Psychology of the Surgical Waiting Room: Personal Observations and Adventures in Waiting

All of us hate waiting in lines.  Our society breeds a “me-first” attitude.  Often the lines in which we wait are slow to move and, we become irritable and angry.  Somehow there is always someone who is able to outsmart the system and get served ahead of their place in the queue. In the typical queue at the grocery store, (or at the apple store genius bar) we become impatient because we want to get what we need and move on with our lives.  The surgical/procedural waiting room is an entirely different beast.  Here, stress, anxiety, uncertainty and fear serve to make even the shortest of waits seem unbearable.  Families sit crouched forward in their uncomfortable chairs watching the door in hopes of seeing the smiling face of their surgeon with every turn of the doorknob.  Here the wait may be rewarded by preservation of a life or, unfortunately, sometimes by a less desirable outcome.

Recently, I had the uncomfortable experience of sitting in the surgical waiting room in support of a patient, not as the physician breezing in to deliver the much anticipated news.  Needless to say this experience has left me wanting to better communicate with my patients’ families as they sit and wait for me to complete a procedure.

While waiting in support of the patient, I began to wonder how families cope with the surgical waiting room.   After a 2 hour journey through the pre-operative process, the patient I was supporting was eventually taken to the operating room and the real wait for family and friends began.  After saying our goodbyes, we were  escorted out to a bare bones waiting area and started to stare at the clock.  Most of my hospital experience has been on the “other side” of the restricted area–time always moved quickly there.  However, on the patient and family side, time crawled and the hands on the clock seemed to be stuck in place…In order to kill time and occupy my mind, I opened my laptop and began to research what had been written in peer reviewed journals concerning waiting for the doctor. 

What I found was quite helpful to me.

Much has been written about the psychology of waiting as it relates to medicine and doctors.  Several principles are common in literature:

1. Unoccupied time feels longer than occupied time
–Lots of  friends came by and checked on our group while  we were waiting.  The conversation was a much needed diversion and stopped me from watching the clock so frequently.  In addition, I was on call and my beeper and phone had to be answered several times during the wait.  The occasional distraction from clock watching really made time jump forward a few times during the ordeal.

2. Anxiety makes waits seem longer
–Boy, is this a true statement.  The procedure was not without risk. Pulmonary Embolus , tearing of venous structures , bleeding and other catastrophic complications were possible.  As I fretted, the clock seemed to stand still.  I began to run thru possible scenarios and how life would be different if a serious complication occurred.  During this time, I heard every click of the second hand on the clock.  The  surgeon called back to the waiting room and spoke to our group via his staff during the procedure to let us know what he had found and what his intraoperative plan was.  This really helped and significantly reduced our anxiety level.  The power of the single phone call update was amazing and will become a routine part of my practice going forward.

3. Uncertain waits seem longer than known finite waits
–When certain expectations are provided, even longer waits become more tolerable.  Providing reasonable estimations of time required for a procedure really makes a significant difference in the quality of the wait.  Certainly, I try to provide family with a time estimate on the high side rather than the low side as to not produce alarm if the procedure goes longer than expected.  Our surgeon did just that and I appreciated the fact that I had reasonable expectations going in.

4. Solo waits seem longer than group waits.
–Having support and company in the waiting room was essential.  Even though I think of myself as tough and able to stand on my own, one cannot underestimate the value of friends, family and clergy during the hours spent in the surgical waiting area.  Fortunately, all three support groups were available during our wait.

Luckily, our  story has a good outcome thus far.  The acute issue was successfully treated and an uncomplicated recovery is expected.   This experience has helped me grow as a physician.   I now have a better understanding of the surgical waiting room and the psychological stressors it places upon loved ones.   I have always emphasized good communication with family members in my practice but I think I can do a better job.  Going forward, I will make every effort to provide each family guidance for the wait.  I will strive to set reasonable expectations as to time, suggest family support during the wait, call from the procedure with updates and provide immediate feedback post-operatively.  Most importantly, I will share these personal observations with my colleagues, medical students, residents and fellows in hopes that they will provide the same courtesy to their patients and families in the future.