Anxiety on admission to a coronary care unit

Journal of Psychosomatic

ANXIETY

Research, Vol. 21, pp. 73 to 78. Pergamon

ON ADMISSION

Press, 1977. Printed in Great Britain

TO A CORONARY

CARE UNIT

N. .I. VETTER,* E. L. CAY-~, A. E. PHILIP*and R. C. STRANGER (Received

5 Jdy

1976)

Abstract-The degree of anxiety was measured, by means of a short questionnaire, in 338 patients with acute ischaemic heart disease immediately after admission to a coronary care unit. Admission to the coronary care unit did not increase anxiety more than that seen in patients admitted as medical emergencies to the general wards. Women were more anxious than men and patients with myocardial ischaemia were more disturbed than those with infarction. Speed of admission to the unit was associated with the clinical state of the patient, not with the degree of anxiety; those with cardiogenic shock or failure being admitted fastest. The way in which patients arrived at the coronary care unit did not affect their degree of anxiety-in particular the use of a mobile coronary care unit for transport of patients to hospital did not alarm the patients. Plasma catecholamines were estimated in 19 of the patients with myocardial infarction. Raised concentrations were associated with the severity of the infarction, not with the individual’s anxiety measurement. High anxiety was found to be associated with mortality in the hospital but not with patients who arrested but were successfully resuscitated, suggesting that anxiety is not a precursor of cardiac arrest of the primary arrhythmic type. ANXIETY in patients

with myocardial infarction has been of concern to clinicians for many years. Some fear that such anxiety might be exacerbated by modern methods of treatment, particularly admission to coronary care units and the use of mobile coronary care units. The results of one study have suggested that this might be a factor where an excess of deaths for patients treated in hospital compared with others treated at home occurred [l]. Several studies have examined anxiety in patients treated in coronary care units [2-41, but all of these reports were derived from assessment when the patients were well settled in the unit or after discharge, when they might have been reassured by their progress or by administration of psychotropic drugs. No measurement of the psychological status of patients immediately after admission to a coronary care unit has yet been reported when the patients’ anxiety would be at a maximum. This had arisen because most existing questionnaires which measure anxiety are too long to be answered by patients when they are acutely ill. In the present study a very short questionnaire, designed to cause minimum disturbance to the patients, was administered to 338 patients with ischaemic heart disease as soon after admission to the coronary care unit as was practicable. This gave a measure of anxiety, which was examined in relation to the mode of admission of the patient, the physical state on admission and the subsequent clinical course of the illness. In some patients blood was taken for estimation of their plasma catecholamine concentrations. BACKGROUND

STUDIES

Two background studies were carried out before the main study was undertaken, in order to validate the melhods used. In the first the results of estimating anxiety by the short questionnaire used in this *Senior Fellow, Community Medicine, Lothian Health Board. +Consultant, Rehabilitation Studies Unit, Astley Ainslie Hospital, Edinburgh. $Director of Psychology, Bangour Hospital, West Lothian. slecturer, Department of Clinical Chemistry, University of Edinburgh. 73

74

N. J. VETTER,E. L.. CAY, A. E. PHIL.IPand R. C. STRAWF

study were compared with those obtained by means of a standard method of quantitating anxiety. 142 male patients attended a follow-up clinic for review of their progress one year after admission to a coronary care unit with ischaemic heart disease. The opportunity was taken to measure their anxiety using form Ci of the Cattell &-parallel Form Battery [5]. At the same time the patients completed the short version of the Neuroticism Scale Questionnaire used in this study. The mean score on the short questionnaire was 5.1 with a standard error of 0.24. For the form G the mean score was 5.4 with a standard error of 0.22. Correlation between the two measures was good (r = 0.5, p < 0.001). The second study used form A of the S-Parallel Form Anxiety Battery to measure anxiety within 24 h of admission in 30 male patients in the general medical wards of the hospital. They had been admitted as emergencies with a variety of illnesses other than ischaemic heart disease. Their mean anxiety score was 5.8 so they were more anxious than a population outside hospital [a, who had a mean score of 5.0. This high mean anxiety score has been confirmed many times previously in patients with peptic ulcer [7] and ischaemic heart disease [8]. STUDY

GROUP

All patients admitted to the coronary care unit over a 4 month period were examined. Of the 415 admitted 338 were later proved to have had ischaemic heart disease and thev comnrised the studv group. Their ages ranged from 38-76 yr with a mean of 57.0. 254 were males, 82 females. 272 patie& had had a myocardial infarction, 208 (76%) of whom were males. 66 patients were diagnosed as having myocardial ischaemia. Myocardial infarction was defined as (a) pathological Q waves in the electrocardiogram with elevation of the appropriate ST segments and subsequent inversion of the T waves; (b) changes in the ST, T waves suggestive of infarction accompanied by a significant and transient rise in serum creatinc kinase activity, or (c) left bundle branch block with similar enzyme changes [9]. Myocardial ischaemia was diagnosed when patients had a classical history of cardiac pain but none of the objective signs or other clinical disease. 244 patients were admitted through the hospital’s accident and emergency department, the rest via the mobile coronary care unit or were transferred from another ward in the hospital (Table 1). The median time from the onset of symptoms until admission to the coronary care unit was 3 h 45 min for the group as a whole. Not surprisingly, patients admitted in the mobile unit reached the coronary cart unit fastest. 85 patients had cardiac failure on admission. This was considered present if there was a raised jugular venous pressure or oedema, a third heart sound or signs of pulmonary oedema on the admission chest X-ray. Of these 85 patients 75 had had a myocardial infarction. Cardiogenic shock was described where the patient had a systolic blood pressure of less than 100 mm Hg, together with sweating pale, cold extremities and possible confusion. Tt was present in 28 cases, 27 of whom had had myocardial infarction. METHOD The questionnaire used to estimate the patient’s degree of anxiety consisted of 10 items from the NeuroticsmScale Questionnaire [lo]. Several considerations influenced the decision to measure anxiety in this way. It was felt inappropriate to use physiological indices, such as heart rate or skin temperature which, at this stage of illness are more related to the physical state of the patient. The method used to measure anxiety had to be short and non-stressful: The nurse who admitted the patient administered the questionnaire. She was told that it was designed to measure the patient’s reaction to the coronary care unit, but not that it was to estimate anxiety, nor did she know how the questionnaire was scored. If the nurse considered that the patient was in any way distressed by the questionnaire she was instructed to stop at once. The questions took on average less than 2 min to complete. Four patients refused to take part in the study. TABLE1.-ADMISSION TO THEUNIT

Mode of admissions Via accident and emergency department Mobile Coronary Care Unit From general medical ward Total group

Number of patients 244 65 29 338

Time of onset of symptoms to admission (median time) 3 hr 59 min 2 hr 50 min 3hr57min 3 hr 45 min

75

Anxiety on admission to a coronary care unit TABLE

~.-+~xETY

ON ADMISSION RELATED

TO SEX, DIAGNOSIS AND

MODE

OF ADMISSION

Mean Anxiety Scores ( f 1SEM) Patient with myo-cardial ischaemia Patients with Ml Total group All patients Males Females Admitted through accident and emergency dept. In Mobile Coronary Care Unit Transfer from general ward

56 5.4 6.3 5.6

f 0.13 f 0.14 & 0.26 & 0.1 s

5.6 f 0.27 6.3 f 0.42

5.6 5.4 60 5.5

f & i 5

0.14 0.16 0.28 0.16

5.7 + 0.32 5.8 i_ 0.46

6.3 5.8 7.5 6.3

f 0.28 & 0.32 f 0.42 & 0.30

5.1 & 0.64 9.3 f 0.75

Plasma catecholamines were estimated in 19 patients with myocardial infarction immediately after they had completed the anxiety measurement. A tri-hydroxy indole fluorescent technique was used I1 11. RESULTS 308 (91%) of the patients completed the anxiety questionnaire, on average 29 min after admission to the coronary care unit. Of the 30 patients who did not have the measurement taken, 21 were unconscious or deeply shocked, 4 refused and 3 were unable to speak English. In two cases the reason was not known. The mean anxiety score for the group as a whole was 5.6. The women were considerably more anxious than the men (t = 3.2, 0.005 > p > 00X) and patients with myocardial ischaemia scored higher than those with infarction (t = 2.1 ,p = 0.04) as shown in Table 2. Mode of admission to the coronary care unit

The degree of anxiety measured was examined in relation to the way in which the patients reached hospital (Table 2). There was no statistically significant difference in anxiety scores between patients admitted through the Accident and Emergency department, the mobile coronary care unit or those transferred from other wards in the hospital for those patients later found to have had a myocardial infarction. Patients with myocardial ischaemia admitted through the Accident and Emergency department were more anxious than those with infarction who came in by the same route (t = 2.19, p = 0.03). The reverse occurred in the 65 patients who came to the coronary care unit in the mobile unit but the difference was not statistically significant. Although the patients with myocardial ischaemia who were transferred from the wards appeared to be very anxious indeed, this group comprised only 4 patients and was probably a spurious result. Severity

ofinfarction and length of symptoms before admission

In the 272 patients with mycocardial infarction early admission to hospital and severity of the attac k as measured by the presence of complications, were related (Table 3). This shows that the more severe the complications the more likely was the patient to reach hospital quickly (xa = 11.52, 002 > p > 0.01). Definitions of cardiogenic shock and failure were given above. There was no relationship between time of admission after the onset of symptoms and the patient’s anxiety measurement. TABLE

S.--TIME BETWEEN ONSET OF SYMPTOMS AND ADMISSION IN RELATION TO CLINICAL STATE AND ANXIETYINPATIENTSWITfIMYOCARDIALINFARCTION

Clinical state on admission Shock Failure Neither Number of patients Mean Anxiety Score

Length of time between onset of symptoms and admission (hr) 2 2-4 4 13 12 41 66 5.3

6 27 50 83 5.4

8 36 79 123 5.8

Number of patients 27 75 170 272

N. J. VETTER,E. L. CAY, A. E. PHILIP and R. C. STRANGE

76

This finding suggests that anxiety is less important than severity of symptoms for hastening the process of a patient’s admission to hospital. This was also tested by comparing the continuousvariables, time after onset of symptoms and anxiety scores. There was no clear correlation between them (v = 0.03, 0.3 > p > 0.2). In the same way, when the 66 patients with myocardial ischaemia were considered it was found that the degree of anxiety and lapse of time between onset of symptoms and admission were not related. Patients with cardiogenic shock appeared to be more anxious (mean score 6.1) than those with cardiac failure (mean score 5.6) or patients without these complications (mean score 5.5), but the differences were not statistically significant at the 5% level. Plasma catecholanline conceiitrations

Plasma catecholamine concentrations were estimated in 19 patients with myocardial infarction just after they had completed the questionnaire. A rough measure of the severity of the attack was estimated by taking the maximum serum activity of creatine kinase over the next 48 hr. This was done to give a continuous estimate of severity. There was a stronglinear relationship between the maximum creatine kinase activity and the catecholamine concentrations on admission (r = 0.79, p < OXIOl). When anxiety measurement and catecholamine concentrations were considered there was no correlation between them (r = 0.13, NS). These findings suggest that at this early stage of illness high concentrations of catecholamine are related to physical severity and extent of infarction, rather than the individual’s psychological state. Clinical course of the acute attack

Of the 272 patients with myocardial infarction 33 (12%) died in the coronary care unit. 18 patients had a cardiac arrest in the unit but were successfully resuscitated to leave hospital alive. 18 (7%) patients died in the medical wards after they had been transferred from the coronary care unit. One patient survived a cardiac arrest in the wards. Anxiety measurements had been made in 12 of the 18 patients who thereafter had a cardiac arrest in the coronary care unit, and in 20 of the 33 who died in the unit. Mean anxiety scores were slightly higher for those who arrested (5.8), but were resuscitated, compared to those who did not arrest (5.5). Those who died showed a higher score (6*3), but these differences were not statistically significant (Table 4). Similarly there was no significant difference in the initial anxiety of those who survived the hospital wards compared to those who died. Mean score can mask a trend which may be more easily discernable at extreme ranges. For this reason the patients with myocardial infarction were divided into three groups: those with high anxiety scores (8-lo), those with moderate scores (5-7) and those with low scores (l-3). The outcome of the attack was examined in these 3 groups (Table 5). The most powerful test for such semi-quantitaTABLF.

‘%.---INITIAL

ANXIETY

IN

PATIENTS

WLTH

COURSE

Medical Ward

TABLE

5.---INITIAL

ACUTE

INFARCTION

Survived Arrest-survived Died Survived Arrest-survived Died

ANXIETY

TO

RELATED

OUTCOME

OF

RELATED

‘IO ‘THE CLINICAL

ATTACK

Number of Number of patients patients tested ._. _ _____-__.221 211 I8 12 33 20 220 204 1 1 18 17

Outcome ___.._~~~ C.C.U.

MYOCARDIAL

OF THE

TREATMEN

Mean Standard Anxiety Score error of mean .-.~~-.-__--.~ 5.5 -t 0.16 5.8 -t 0.61 6,3 r_t-0.56 5.5 zt 0.15 8.0 5.8 G68 IN

PATIENTS

WITH

MYOCARDIAL

INFARCTION

Outcome of hospital treatment

Number of patients

Died Survived

51 221

Test for trend c = 2.12, p = 0*03.

Number tested

_.._.___

37 (73 %) 205 (93 %)

Level of anxiety _~__ Low (l--3) Moderate (4.-7)

.~~~______-.. 4 42

-~~~

20 124

___High (8.-10) 13 39

Anxiety on admission to a coronary care unit

II

tive data is a test for trend, which assigns a numerical value to the data in sequence. An expected value and variance can then be calculated [12]. Using this method there was a trend for more deaths to occur in those patients who were most anxious on admission, but there was no such trend it

patients with a cardiac arrest, which they survived, were compared to survivors with no arrest. DISCUSSION Studies of patients with ischaemic heart disease who have been admitted to coronary care units have suggested that such units can be reassuring 12-41. The results from the present group of patients showed that within half an hour of their admission to a coronary care unit patients were not more anxious than others admitted as medical emergencies to hospital wards. Early admission to hospital was dictated by the clinical state of the patient, those obviously shocked or in cardiac failure came in quickly. Anxiety did not appear to play much part in determining the speed of admission. The way in which a patient reached hospital did not affect his anxiety. The development of mobile coronary care units has been criticized on the grounds that this would increase alarm and distress in these patients and possibly the incidence of cardiac arrhythmias. The patients who come to the hospital in the mobile coronary care unit were not more anxious, though they reached the unit 1 hr earlier, having been monitored and stabilized in the mobile unit for some time before they arrived. A previous study indicated that patients with myocardial ischaemia were more anxious than those with a confirmed infarction, when they were assessed during convalescence in the medical wards [8]. The results of the present study suggested that they are more anxious from the beginning of their illness. This may be a reflection of the uncertainty of the diagnosis of myocardial ischaemia reflecting itself in the patient’s anxiety that he may or may not have had a “heart attack”, or it may be due to self-selection of the more anxious patients for admission to hospital despite relatively minor symptoms. Women admitted to the coronary care unit were more anxious than men. Studies of most forms of emotional upset in general practice [13] and in those awaiting surgery [14] have also shown that disturbance is higher in women than in men. Such emotional factors hindered successful rehabilitation after a heart attack in males [15]. If this M/as also true of female patients then recognition that their anxiety was increased would make treatment to relieve this an important part of their management. Initial anxiety was not higher in patients who subsequently survived a cardiac arrest. It seems unlikely therefore that anxiety was a potent cause of reversible cardiac arrest of the primary arrhythmic type. The finding that patients who died tended to be more anxious at the beginning of their illness suggested that those who died, usually of cardiogenic shock or cardiac failure, may have had premonitory symptoms which increased their anxiety. Another factor which may have played a part was the attitude of attendant medical staff and relatives towards the very ill person. Studies on various groups have claimed that there is a relationship between plasma catecholamine concentrations and the degree of anxiety [16, 171. This was not the case in our patients in whom severity of infarct and concentration of plasma catecholamines were closely related. This, together with the evidence that anxiety by itself appears to exert little change upon the clinical course of the acute attack suggests that, at this very early stage of illness, the gross physiological disturbances caused by the infarction itself are of much greater significance.

7X

N. J. VETTER, E. L. CAY, A. E. PHILIP and R. C. STRANGE

Acknowledgemenfs-The authors are indebted to Professor K. W. Donald, Department of Medicine, Dr M. F. Oliver, Department of Cardiology of the Royal Infirmary of Edinburgh and Professor D. G. Julian, Department of Cardiology, Royal Victoria Hospital, Newcastle upon Tyne, for their support and advice during the course of this study. We would especially like to thank the nursing staff of the Coronary Care Unit, Royal Infirmary of Edinburgh. This study was supported by grants from the Scottish Hospitals Endowment Research Trust (N.J.V.) and the Scottish Home and Health Department. REFERENCES 1. MATHER H. G., PEARSONN. G., READ K. L. O., SHAW D. B., STEEDG. R., THORNEM. G.,

2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

17.

JONESS.. GUERRIERC. J., ERANT C. D., MCHUGH P. M.. CHAWDHORYN. R.. JAFERYM. H. and WALLACET. J. Acute myocardial infarction: home and hospital treatment: Br. Med. J. 3, 334 (1971). DOMINIONJ. and DOBSONM. Study of patient’s psychological attitudes to a coronary care unit. Br. Med. J. 4,795 (1969). HAKKETTT. P., CA~SEMN. H. and WISHNIEH. A. The coronary care unit:an appraisal of psychological hazards. New Ennl. J. Med. 279, 1365 (1968). CRY E. L., VETTERN., PHILIP A. E. and DU&RD P. Psychological reactions to a coronary care unit. J. Psychosom. Res. 16, 437 (1972). SCHEIERI. H. and CAT~ELLR. B. Handbook for the I.P.A.T. 8-parallel form anxiety battery. I.P.A.T. (1960). PHILIP A. E. Evaluation of the Cattell 8-parallel form anxiety battery. Br. J. Psycho/. 63, 573, (1972). P~LIP A. E. and CAY E. L. Psychiatric symptoms and personality traits in patients suffering from gastro-intestinal illness. J. Psychosom. Res. 16, 47 (1972). CAY E. L., VETTERN., PHILIP A. E. and DUCAR~ P. Psychological status during recovery from an acute heart attack. J..Psychosom. Res. 16,425 (1972): LAWRIED. M.. GREENWOODT. W.. GODDARDM.. HARVEYA. C.. DONALDK. W.. JULIAN D. G. and OLIVERM:F. A coronary care unit in the treatment of acute myocardial infarction. Larzcet 2, 109 (1967). CATTELLR. B. The Specific Analysis of Personality. Penguin, Harmondsworth (1965). SINGERSD. C., SALTERC. and FLUCK D. C. Serial plasma adrenaline and noradrenaline levels in myocardial infarction using a new double isotope technique. Br. Heart J. xxxiii, 878 (1971). Cox D. R. Tlte Analysis of Binary Data, section 5.4. Methucn Monograph, London (1970). SHEPHERDM., COOPERB., BROWNA. C. and KALT~N G. W. Psychiatric IIlness in General Practice. Oxford University Press, Oxford (1966). WEISS S. M. Psychosomatic aspects of symptom patterns among major surgery patients. J. Psychosom. Res. 13,109 (1969). CAY E. L., VETTERN., PHILIP A. and DUGARDP. Return to work after a heart attack. J. Psychosom. Res. 17,231 (1973). FRIEDMANM., ST. GEORGES., BYERSS. 0. and ROSENMANR. H. Excretion ofcatecholamines, 17 Ketosteroids, 17 hydroxy corticoids and 5 hydroxyindole in men exhibiting a particular behaviour pattern (A) associated with high incidence of clinical coronary artery disease. J. C/in. Invest. 39, 758 (1960). MCDONALDL., BRAYC., MCDONALDA. and RES~IEAUXN. Plasma catecholamines after cardiac infarction. Lance? 2, 102 (1969).