Healing the heart after an acute cardiac event

Coronary heart disease is a growing public health threat and remains the major cause of death both in Australia and worldwide. One in six Australian adults has heart disease, equating to around 3.4 million people at any time. Each year, more than 55,000 Australians have a heart attack, with many undergoing cardiac surgery. The acute cardiac event is not only a physical assault on the body, it is also an emotionally traumatic and significant life event for those who experience it, and for their families. Psychologists have an important role to play in the identification and management of post-cardiac event mental health issues. 

A physical heart event brings with it a range of unexpected, distressing and often debilitating emotional, behavioural and cognitive changes known as the cardiac blues. Around the time of the heart event, people typically feel shocked, fearful, traumatised, sad and anxious. Common symptoms include tearfulness, sleep disturbance and nightmares, low or fluctuating mood, reduced self-esteem, concerns about role changes including paid work, physical health and independence, loss of pleasure in usual activities, changes in appetite and sex drive, and pessimism about the future. Even those who have ‘never been emotional’ can become tearful, worried, insecure about their future, and mentally and emotionally exhausted (Murphy et al., 2016). 

The cardiac blues

Anxiety and depression are both common after an acute cardiac event such as heart attack or bypass surgery. In a recent Australian study undertaken by the Australian Centre for Heart Health and involving over 900 patients admitted to hospital after heart attack or to undergo surgery, over 40 per cent had elevated anxiety and over 20 per cent had symptoms of depression in the weeks immediately after hospital discharge (Murphy et al., 2020). These rates are up to four times higher than those typically seen in the Australian population. 

Concerningly, the heart event continues to take an emotional toll in the year that follows. The same study of 900 people demonstrated that over one in four had significant anxiety and almost one in five were depressed by six to 12 months after the acute event (Murphy et al., 2020). While for some the symptoms had resolved, others had developed new onset anxiety or depression during the convalescent period. This latter group is at particular risk: when mental health issues emerge after people have recovered physically, they are more at risk of falling through the gaps in terms of access to supports and services, and even in being able to engage the support of family and friends. 

Post-event anxiety and depression can be fatal. Both conditions – along with post-traumatic stress, loneliness and isolation, and major psychiatric disorders – are associated with a significantly elevated risk of experiencing another heart event and of premature death (Murphy, Rogerson et al., 2013; Murphy et al., 2016; Jackson et al., 2018; Jackson & Murphy, 2019). In addition, post-event mental health issues reduce people’s quality of life (Worcester et al., 2007) and precipitate a plethora of other social difficulties including loss of paid employment and relationship challenges (Tully & Higgins, 2014).

Who is most at risk?

A range of sociodemographic, behavioural and medical factors increase the risk of mental health problems after an acute cardiac event. Factors consistently associated with elevated anxiety and depression risk are having had mental health issues prior to the cardiac event, experiencing significant financial strain or being of lower socioeconomic status, being younger (aged under 55), having poorer physical health or other comorbidities such as diabetes or obesity, being socially isolated or living alone, recent bereavement, and cigarette smoking (Murphy et al., 2014; Murphy et al., 2020). These risk factors or ‘red flags’ can be used to alert health professionals to the increased likelihood that a person will experience persistent or complicated mental health concerns that require professional support. 

Maintaining a healthy lifestyle

Post-event mental health issues compromise people’s ability to take care of themselves, to manage their health behaviours and to make recommended lifestyle changes after the acute cardiac event. Compared to their non-distressed counterparts, those who are anxious or depressed are less likely to take their cardiac medications as prescribed or to attend cardiac rehabilitation; they have a less healthy diet, are less physically active and are more likely to smoke (Murphy et al., 2012). 

Up to 90 per cent of the overall risk of an acute heart event can be attributed to modifiable risk factors. After a heart attack or heart surgery, adherence to cardiac medications can halve the risk of a future event while quitting smoking will reduce post-event mortality risk by 36 per cent in the 3–5 years after quitting (Wald & Law, 2003). Yet, by 12 months post-event, around 50 per cent of those who are depressed do not take medications as prescribed. Moreover, half of those who quit smoking at the time of the event have resumed; people with a mental health condition are far more likely to fall into this category. 

Even in the absence of mental health issues, behaviour changes are difficult, both to make and to sustain. For people with anxiety or depression, the need for professional psychological support in making and sustaining life-enhancing behaviour changes is even more critical. 

Role of psychologists

Psychologists have an important role in supporting the mental and behavioural health of people after an acute cardiac event . This includes clinical assessment, treatment recommendations, and depression-focused psychotherapy (Tully & Higgins, 2014). Cognitive behaviour therapy and problem-solving therapy are the frontline non-pharmacological interventions for depression in people with heart disease (Jackson et al., 2015; Tully & Higgins, 2014).

The Australian Centre for Heart Health has demonstrated that group-based cognitive behaviour therapy, incorporating tailored motivational interviewing strategies with a cardiac focus, can improve both the mental and physical health of people after an acute heart event (Murphy et al., 2013; Turner et al., 2014). 

A randomised controlled trial of the eight-week group-based program, involving 275 people admitted to the Royal Melbourne and Melbourne Private hospitals after heart attack or for heart surgery, demonstrated reduced risk of a recurrent event (Murphy et al., 2013) and reduced incident depression (Turner et al., 2014) for those in the treatment arm. Both online (Higgins et al.,2017) and telephone-delivered (Higgins et al., 2017) versions of the program have since been developed.

Specialised psychological support

Often people who have had an acute and traumatic event appreciate or even require support from a team of professionals dedicated to and experienced in the specific condition. The Australian Centre for Heart Health is dedicated to improving the lives of people with heart disease. Through its Cardiac Wellbeing Program, the Centre delivers a range of psychosocial support programs based on over three decades of research into the psychological aspects of cardiac recovery. In particular, the Centre offers individual counselling with expert cardiac psychologists to provide specialised psychological support for people with heart disease and their families. 

The service includes face to face, telephone and internet options for people in metropolitan, regional, rural or remote areas of Australia. The Centre also offers support for parents of children with congenital heart conditions, again based on its evidence-based programs (Jackson et al., 2019). People can access the Cardiac Wellbeing Program through a Mental Health Plan or a Chronic Disease Management Plan, both of which can be obtained through referral from a general practitioner. 

The Australian Centre for Heart Health is a not-for-profit, independent Medical Research Institute and a National Health & Medical Research Council (NHMRC) administering organisation. The Centre is a collaborating centre of Deakin University through the Faculty of Health, and is affiliated with the University of Melbourne through the Faculty of Medicine, Dentistry and Health Sciences.

The authors can be contacted at [email protected]

Author credits: Australian Centre for Heart Health,;School of Psychological Sciences, University of Melbourne; Faculty of Health, Deakin University; Department of Physiotherapy, University of Melbourne; Centre on Behavioural Health, University of Hong Kong