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Psychosocial adjustment of patients arriving early at the emergency department after acute myocardial infarction
Psychosocial Adjustment of Patients Arriving Early at the Emergency Department After Acute Myocardial Infarction Robert M. Carney, PhD, KennethE. Freedland,PhD, KarenA. Clark, BA, Judith A. Skala,RN, BA, LaurieJ. Smith, BA, AlanDelamater,PhD, and AllanS. Jaffe, MD
The psychosocial functioning of patients arriving at the emergency department with an acute myocardial infarction earfy enough to be candldates for treatment with thrombolytk agents was compared with that of those arriving later. Patients who arrived within 3 hours were significantly mere anxious when assessed 1 week after admission and had a consistently worse pattem of psychosocialadjustment 3 months after hospital discharge than did those who arrived later. The imptications of these fldngs for efforts to improve early arrival at the emergency department, as well as for medical and psychosocial outcomes after acute myocardial infarct&w, were cenddered. (AmJCardiol1992;69:160-163)
T
reatment with thrombolytic agents improves survival in patients with acute myocardial infarction (AMI).1-5 The benefit is substantially greater when patients receive thrombolytic agents early after the onset of AMI.1-5 Furthermore, early access to medical care is important regardless of whether thrombolytic therapy is administered, because deaths from malignant arrhythmias usually occur early after the onset of AMI. Unfortunately, many patients do not seek immediate treatment. Prolonged delay is the most frequent contraindication to use of thrombolytic agents.*-5 Therefore, many physicians advocate programs designed to minimize such delays. Little is known about the psychosocial functioning of patients who arrive early compared with that of those who arrive later. Because early arrival is likely to improve medical prognosis, such patients may also have a better psychosocial outcome. However, these patients may arrive early because they are anxious, depressed or somatically preoccupied. These factors are known to From Washington University School of Medicine, St. Louis, Missouri. This study w&supported in &t by USPHS Grant 1 ROl Hti2427-01 from the National Heart, Lung, and Blood Institute, and the National Research Demonstration Center Grant, SCOR in Ischemic Heart Disease, Grant HL17646, from the National Institutes of Health, Bethesda, Maryland. Manuscript received July l&1991; revised manuscript received and acceDtedSex&n&x 16,199 1. Address for r&rints: kobert M. &mey, PhD, Behavioral Medicine Center, Jewish Hospital of Saint Louis, 216 S. Kingshighway Blvd., St. Louis, im
Missouri
63 110.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
predict adverse psychosocial outcomes, independent of medical status.7-9 Accordingly, we compared the psychosocial functioning during hospitalization and 3 months after discharge of patients with initial Q-wave AM1 who arrived at the emergency department early (i.e., within the window of opportunity for thrombolytic therapy) with that of those who arrived later. MErwDs Subjeetsr Subjects were recruited from a sequential series of patients with documented Q-wave AM1 who were admitted to the cardiac care unit. Patients included in the study had to be: (1) aged <70 years, (2) able to recall the time of onset of symptoms of AMI, (3) able to undergo an interview and psychometric assessment, (4) willing to provide informed consent, and (5) permitted by their cardiologist to participate. Patients were excluded from the study if they: (1) had history of AMI, coronary disease or any cardiac procedure, including catheterization, (2) had congestive heart failure or valvular heart disease (except mitral valve prolapse), (3) had any other chronic medical illness, (4) had significant cognitive impairment as determined by a minimental status examination, or (5) were located farther than a 3Ominute drive from the hospital at the time of onset of symptoms. Forty-two of 124 patients screened for recruitment met these criteria and were enrolled within 5 days of AMI. During this study patients were eligible for thrombolytic treatment only if they arrived within 3 hours after the onset of symptoms. Accordiiy, patients who arrived within 3 hours were classitied as early arrivers, and patients who arrived later were classified as late arrivers. Proce&w A~~F~ME~DURINOH~~PITALIZATI~N: Patients were administered the Hopkins Symptom Checklist 90, Revised.lO The Symptom Checklist is a widely used self-report measure of somatization, depression, anxiety, obsessive-compulsive symptoms, interpersonal sensitivity, phobic anxiety, hostility, paranoid ideation and psychoticism. Patients were also administered the Jenkins Activity Survey,li a self-report measure of the type A behavior pattern. The times of symptom onset and arrival to the emergency department were documented by the emergency department staff and noted in each patient’s chart. FOLLOW-UP: Three months after hospital discharge, patients were administered the Psychosocial AdjustJANUARY
15. 1992
TABLE I Demographic Hospitalization
and Medical
Age Married Men/women Severity of CAD* LVEF Percentage of AMls occurring during daytime
Characteristics
at Index
Early Arrivers
Late Arrivers
54 + 10 36(86%)
51 r8
3319 1.83 + 1.03 51 f 14 61%
33(79%) 30112 1.80 + .92 49 + 16
57%
*Number of vessels occluded t 50%. AMls = acute myocxdial infarctions; CAD = coronary artery disease: LVEF = left ventricular ejection fraction.
ment to Illness Scale,‘* a self-report measure of psycho social adjustment to medical illness in terms of general health, work capacity, domestic atmosphere, sexual performance, family and social support, and psychological distress. RESULTS Twenty-five patients arrived at the emergency department within 3 hours after the onset of symptoms (mean 1.4 f 0.7), and 17 arrived after 3 hours (mean 5.5 f 8.2). No late arriver and 17 early arrivers (68%) received treatment with thrombolytic agents. Twenty-four early and 15 late arrivers subsequently underwent cardiac catheterization. There were no differences between the 2 groups in left ventricular function or severity of coronary artery disease (Table I). There were also no differences in any of the other medical and demographic variables that were assessed. Psychological test results during hospitalization are listed in Table II. Early arrivers scored significantly higher on the anxiety and phobic anxiety scales of the Symptom Checklist. None of the other scores were significantly different between the groups. There was no difference between the groups on the Jenkins Activity Survey. All but 1 of the early (96%) and 1 of the late (94%) arrivers completed the follow-up assessment (Table III). The number of subjects varied slightly (38 to 40) across analyses, because certain items or subtests (e.g., employment-related questions) were not applicable in some cases. Early arrivers scored significantly higher on all 7 subtests of the Psychosocial Adjustment to Illness Scale, suggesting a worse pattern of psychoso cial adjustment to illness during the 3 months after the initial AMI. DISCUSSION This study found that early arrivers were more anxious than later arrivers and had a worse psychosocial adjustment at 3 months. Moreover, early arrivers scored nonsignificantly higher on all but 1 scale of the Symp tom Checklist, suggesting the possibility of greater general emotional distress than that of late arrivers. No patient in either group had history of cardiac disease. All patients reported chest pain during AMI. Thus, there were no identifiable differences in medical history or symptoms that may have influenced the decision to go to the hospital. Furthermore, no differences in demographic characteristics on admission or in extent of carPSYCHOSOCIAL
TABLE II Comparison Checklist for Patients Early Versus Late
of Jenkins Activity Survey and Symptom Arriving to the Emergency Department Early Arrivers*
Scales Jenkins Activity Survey Type A score Symptom checklist Somatization Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Positive symptom total Global severity index
Late Arrivers*
t
p Value
248287
243 k 73
0.88
NS
1.1 f 0.8 0.7 2 0.7
0.7 0.5 0.5 0.6 0.3 0.3 0.1 0.3 0.2
1.57 0.87 -0.11 1.11 1.97 1.08 1.99 0.87 1.58
NS NS NS NS
0.4 2 0.5 0.9 * 0.9
0.7 0.5 0.3 0.5 0.4 30.2
k 2 k r -c
0.8 0.8 0.6 0.5 0.5
2 21.1
0.7 e 0.6
20.8
t + k + + + + -t 2
0.7 0.7 0.7 0.8 0.5 0.4 0.2 0.4 0.3
+ 18.8
0.4 + 0.6
1.48
1.48
<0.05 NS
<0.05 NS NS NS NS
*Mean f standard deviation. NS = not significant.
TABLE Ill Comparison Illness for Early Versus Subscale
of the Psychosocial Adjustment to Late Arrivers at Three-Month Follow-Up Early Arrivers*
Late Arrivers*
13.5 * 4.2
10.9 * 5.4
2.12
0.04
8.7 t 2.7
1.90
0.06
Health care orientation Vocational environment Domestic environment Sexual relations Extended family Social environment Psychological distress
10.0 k 2 14.4 2 3.1
10.0 z!z 2.6 6.8 2 2.2 9.3 -c 2.1 11.7? 3.2
11.6 + 4.2
8.4 5.4 7.9 9.3
-t + + r
4.3 3.1 3 4.2
t
p Value
2.92
0.006
1.98 2.36 2.36 2.69
0.05 0.02 0.02 0.01
*Mean ? standard deviation. -I
diovascular disease were subsequently found. Conse quently, the psychosocial differences that were found cannot be easily explained by differences in demographics, ventricular function or disease severity. This outcome could be an unexpected effect of thrombolytic treatment rather than of early arrival. To test this hypothesis, we compared the 7 scales of the Psychosocial Adjustment to Illness Scale of the 8 patients who did not receive thrombolytic therapy, despite arriving early enough to the emergency department to be eligible, with the scores of the 17 who did receive it. There were no differences on any of the 7 scales. In fact, the means were nearly identical (p >0.60). Thus, poorer psychosocial adjustment appears to be associated with relatively early arrival at the emergency department and not with thrombolytic therapy. It is possible that the patients who arrived early may have done so in part because they were more anxious than were the later arrivers after the onset of AMI. However, it is possible that the early arrivers became more anxious after their hospital admission for reasons that are currently unclear. In any case, there may be reason to be concerned. Previous studies have documented increased mortality and both medical and psychological morbidity in anxious, depressed or stressed patients with a recent AMI.13-16 If anxiety or other forms of emotional distress are detected in early arrivers, these patients may need psychological treatment afADJUSTMENT
AFTER
ACUTE
MYOCARDIAL
INFARCTION
161
ter they are medically stabilized. If their anxiety were treated after admission, both the long-term medical and psychosocial prognosis of these patients may be improved. There is already evidence that such an intervention may have a beneficial effect. Frasure-Smith and PrinceI randomly assigned patients after AM1 to either standard care or standard care plus, a stress reduction intervention. After 1 year, these patients had lower stress scores and fewer cardiac deaths than did control subjects. Earlier studies documented other psychological differences between late and early arrivers to the emergency department after the onset of AMI. Theorell et all8 found that the inability to relax during leisure time (an aspect of the type A behavior pattern) was associated with a shorter delay in arrival. However, Matthews et alI9 found that patients who delayed in deciding that they were ill after onset of symptoms tended to exhibit type A behavior. Patients who delayed seeking treatment after deciding they were ill tended to exhibit type B behavior. We did not find differences between our early and late arrivers on our type A measure. Matthews used the Structured Interview to assessthe type A behavior pattern, whereas we used the Jenkins Activity Survey self-report inventory. The Interview may be more sensitive than the Jenkins scale to the relevant type A features. Although denial was not assessedin this study, it is possible that patients who arrived late were less anxious than early arrivers, because they were denying the seriousness or even the reality of their AMI. However, Hackett and Cassem*O did not find a relation between denial and time of arrival to the emergency department in patients with AMI. They found that other factors (such as another person insisting that the patient go to the emergency department) played a more important role. Many patients engage in some form of denial after AMI, and this denial is usually associated with reduced anxiety while in the cardiac care unit.*] Levine et al** found that patients who strongly denied their illness tended to spend fewer days in the cardiac care unit and had fewer signs of cardiac dysfunction during hospitalization. However, in the year after hospital discharge, strong deniers adapted more poorly. Our late arrivers, however, continued to do well 3 months after discharge. The role of denial in late arrival needs further investigation. In conclusion, this study found that patients who arrived at the hospital early after onset of symptoms were more anxious during hospitalization and had a worse psychosocial adjustment in the 3 months after AMI. Psychotherapeutic intervention may be useful in these patients, because studies have shown that high levels of anxiety after AM1 are associated with a poor medical prognosis and worse psychosocial adjustment. In addition, further research is needed to develop strategies
162
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
that encourage early hospital admission without unnecessarily increasing anxiety. Unfortunately, the conclusion of Hackett and Cassem*l nearly 25 years ago still applies today: “. . . we know almost nothing about the social, psychological, or genetic factors that facilitate or inhibit the process of delay. . . .” Further research with larger samples of patients is clearly needed to delineate the psychological and social determinants of the decision to go to the emergency department when symptoms of AM1 occur, and to understand the factors affecting the psychosocial adjustment of early arrivers.
REFERENCES
1. Gmppo Italian0 per lo Studio Della Streptochiiasi Nell’Infarto Miocardico. Effectiveness of intravenous thmmbolytic treatment in acute myocardial infarction. Lance? 1986;1:397-401. 2. Kennedy JW, Ritchie JL, Davis KB, Fritz DK. Western Washington randomized trial of intracoronary streptokinase in acute myocardial infarction. N Engf J Med 1983;308:1312-1318. 3. Wilcox RG, von der Lippe G, Olsson CG, Jensen G, Skene AM, Hampton JR. Trial of tissue plasminogen activator for mortality reduction in acute myocardial infarction; Angl&candinavian Study of Early Thrombolysis (ASSET). fun& 1988;2:525-530. 4. AIMS Trial Study Group. AIMS trial study group: effect of intravenous APSAC on mortality after acute myocardiil infarction: preliminary report of placebo-controlled trial. Lancer 1988;1:545-549. S. Second International Study of Infarct Survival. Collaborative group: randomixd trial of intravenous streptokinase, oral aspirin, both, or neither among 17,187 cases of suspected acute myocardiil infarction: ISIS-I. Lnncet 1988;2: 349-360. 6. Lawrie DM. Hinains MR. Godman MJ. Julian DG. Donald KW. Ventricular fibrillation coipligting a&e myaxrdiai infarction. ‘Loneet 1968;2:523-528. 7. Cay EL, Vetter N, Philip AE, Dugard P. Psychological status during recovery from an acute heart attack. J Psycharom Res 1972;16:425-435. 6. Mayou R, Foster A, Williamson B. Psychosocial adjustment in patients one year after myocardial infarction. J Psychosom Res 1978;22:447-453. 9. Lloyd GG, Cawley RH. Distress or illness? A study of psychosocial symptoms after myocardial infarction. Br J Psychiatry 1983;142:120-125. 10. Derogatis LR. The SCL-90 Manual. Baltimore: Johns Hopkins University, 1977. 11. Jenkins CD, Zyzanski SJ, Rosenman RH. Progress toward validation of a computer-scored test for the type A coronary-prone behavior pttem. Psychosom .&fed 1971;33:193-202. 12. Derogatis LR. The Psychosocial Adjustment to Illness Scale Administration & Scoring Manual. Baltimore: Clinical Psychometric Research, 1977. 13. Stem JJ, Paxale L, Ackerman A. Life adjustment post myocardial infarction: determining predictive variables. Arch Intern Med 1977;137:1680-1685. 14. Garrity TF, Klein RF. Emotional response and clinical severity as early determinants of six-month mortality after myocardial infarction. He& Lung 1975;4:730-737. 15. Falger P, Appels A. Psychological risk factors over the life course of myocardial infarction patients. Adu Cordial 1982;29:132-139. 16. Schleifer SJ, Macari MM, Slater W, Kahn M, Zucker H, Gorlin R. Predictors of outcome after myocardiil infarction: role of depression. Circulorion 1974;2:2-10. 17. FrasureSmith N, Prince R. Long-term follow-up of the ischemic heart disease life stress monitoring program. Psychasom Med 1989;51:485-513. 16. Theorell LR, Erhardt LR, Lind E, Sjogren A, Sawe U. Selected psych&al variables in the delay of reaching the coronary care unit. Acre Med Stand 1975;198:315-317. 19. Matthews KA, Siegel JM, Kuller LH, Thompson M, Varat M. Determinants of decisions to seek medical treatment by patients with acute myocardial infare tion symptoms. J Pen Sot Psycho1 1983;44:1144-1156. 20. Hackett PP. Cassem NH. The psychologic reactions in patients in the pre and post hospital phase of myocardial infarction. Postgrad Med 1975;57:43-46. 21. Hackett TP, Cassem NH. Factors contributing to delay in reqonding to the signs and symptoms of acute myocardial infarction. Am J Cordial 1969;24: 651-659. 22. Levine J, Warrenburg S, Kerns G, Schwartz D, Fontana A, Gradman A, Smith S, Allen S, Cascione R. The mle of denial in recovery from coronary heart disease. Psychosom Med 1987;49:109-117.
JANUARY
15, 1992
The psychosocial functioning of patients arriving at the emergency department with an acute myocardial infarction earfy enough to be candldates for treatment with thrombolytk agents was compared with that of those arriving later. Patients who arrived within 3 hours were significantly mere anxious when assessed 1 week after admission and had a consistently worse pattem of psychosocialadjustment 3 months after hospital discharge than did those who arrived later. The imptications of these fldngs for efforts to improve early arrival at the emergency department, as well as for medical and psychosocial outcomes after acute myocardial infarct&w, were cenddered. (AmJCardiol1992;69:160-163)
T
reatment with thrombolytic agents improves survival in patients with acute myocardial infarction (AMI).1-5 The benefit is substantially greater when patients receive thrombolytic agents early after the onset of AMI.1-5 Furthermore, early access to medical care is important regardless of whether thrombolytic therapy is administered, because deaths from malignant arrhythmias usually occur early after the onset of AMI. Unfortunately, many patients do not seek immediate treatment. Prolonged delay is the most frequent contraindication to use of thrombolytic agents.*-5 Therefore, many physicians advocate programs designed to minimize such delays. Little is known about the psychosocial functioning of patients who arrive early compared with that of those who arrive later. Because early arrival is likely to improve medical prognosis, such patients may also have a better psychosocial outcome. However, these patients may arrive early because they are anxious, depressed or somatically preoccupied. These factors are known to From Washington University School of Medicine, St. Louis, Missouri. This study w&supported in &t by USPHS Grant 1 ROl Hti2427-01 from the National Heart, Lung, and Blood Institute, and the National Research Demonstration Center Grant, SCOR in Ischemic Heart Disease, Grant HL17646, from the National Institutes of Health, Bethesda, Maryland. Manuscript received July l&1991; revised manuscript received and acceDtedSex&n&x 16,199 1. Address for r&rints: kobert M. &mey, PhD, Behavioral Medicine Center, Jewish Hospital of Saint Louis, 216 S. Kingshighway Blvd., St. Louis, im
Missouri
63 110.
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
predict adverse psychosocial outcomes, independent of medical status.7-9 Accordingly, we compared the psychosocial functioning during hospitalization and 3 months after discharge of patients with initial Q-wave AM1 who arrived at the emergency department early (i.e., within the window of opportunity for thrombolytic therapy) with that of those who arrived later. MErwDs Subjeetsr Subjects were recruited from a sequential series of patients with documented Q-wave AM1 who were admitted to the cardiac care unit. Patients included in the study had to be: (1) aged <70 years, (2) able to recall the time of onset of symptoms of AMI, (3) able to undergo an interview and psychometric assessment, (4) willing to provide informed consent, and (5) permitted by their cardiologist to participate. Patients were excluded from the study if they: (1) had history of AMI, coronary disease or any cardiac procedure, including catheterization, (2) had congestive heart failure or valvular heart disease (except mitral valve prolapse), (3) had any other chronic medical illness, (4) had significant cognitive impairment as determined by a minimental status examination, or (5) were located farther than a 3Ominute drive from the hospital at the time of onset of symptoms. Forty-two of 124 patients screened for recruitment met these criteria and were enrolled within 5 days of AMI. During this study patients were eligible for thrombolytic treatment only if they arrived within 3 hours after the onset of symptoms. Accordiiy, patients who arrived within 3 hours were classitied as early arrivers, and patients who arrived later were classified as late arrivers. Proce&w A~~F~ME~DURINOH~~PITALIZATI~N: Patients were administered the Hopkins Symptom Checklist 90, Revised.lO The Symptom Checklist is a widely used self-report measure of somatization, depression, anxiety, obsessive-compulsive symptoms, interpersonal sensitivity, phobic anxiety, hostility, paranoid ideation and psychoticism. Patients were also administered the Jenkins Activity Survey,li a self-report measure of the type A behavior pattern. The times of symptom onset and arrival to the emergency department were documented by the emergency department staff and noted in each patient’s chart. FOLLOW-UP: Three months after hospital discharge, patients were administered the Psychosocial AdjustJANUARY
15. 1992
TABLE I Demographic Hospitalization
and Medical
Age Married Men/women Severity of CAD* LVEF Percentage of AMls occurring during daytime
Characteristics
at Index
Early Arrivers
Late Arrivers
54 + 10 36(86%)
51 r8
3319 1.83 + 1.03 51 f 14 61%
33(79%) 30112 1.80 + .92 49 + 16
57%
*Number of vessels occluded t 50%. AMls = acute myocxdial infarctions; CAD = coronary artery disease: LVEF = left ventricular ejection fraction.
ment to Illness Scale,‘* a self-report measure of psycho social adjustment to medical illness in terms of general health, work capacity, domestic atmosphere, sexual performance, family and social support, and psychological distress. RESULTS Twenty-five patients arrived at the emergency department within 3 hours after the onset of symptoms (mean 1.4 f 0.7), and 17 arrived after 3 hours (mean 5.5 f 8.2). No late arriver and 17 early arrivers (68%) received treatment with thrombolytic agents. Twenty-four early and 15 late arrivers subsequently underwent cardiac catheterization. There were no differences between the 2 groups in left ventricular function or severity of coronary artery disease (Table I). There were also no differences in any of the other medical and demographic variables that were assessed. Psychological test results during hospitalization are listed in Table II. Early arrivers scored significantly higher on the anxiety and phobic anxiety scales of the Symptom Checklist. None of the other scores were significantly different between the groups. There was no difference between the groups on the Jenkins Activity Survey. All but 1 of the early (96%) and 1 of the late (94%) arrivers completed the follow-up assessment (Table III). The number of subjects varied slightly (38 to 40) across analyses, because certain items or subtests (e.g., employment-related questions) were not applicable in some cases. Early arrivers scored significantly higher on all 7 subtests of the Psychosocial Adjustment to Illness Scale, suggesting a worse pattern of psychoso cial adjustment to illness during the 3 months after the initial AMI. DISCUSSION This study found that early arrivers were more anxious than later arrivers and had a worse psychosocial adjustment at 3 months. Moreover, early arrivers scored nonsignificantly higher on all but 1 scale of the Symp tom Checklist, suggesting the possibility of greater general emotional distress than that of late arrivers. No patient in either group had history of cardiac disease. All patients reported chest pain during AMI. Thus, there were no identifiable differences in medical history or symptoms that may have influenced the decision to go to the hospital. Furthermore, no differences in demographic characteristics on admission or in extent of carPSYCHOSOCIAL
TABLE II Comparison Checklist for Patients Early Versus Late
of Jenkins Activity Survey and Symptom Arriving to the Emergency Department Early Arrivers*
Scales Jenkins Activity Survey Type A score Symptom checklist Somatization Obsessive-compulsive Interpersonal sensitivity Depression Anxiety Hostility Phobic anxiety Paranoid ideation Psychoticism Positive symptom total Global severity index
Late Arrivers*
t
p Value
248287
243 k 73
0.88
NS
1.1 f 0.8 0.7 2 0.7
0.7 0.5 0.5 0.6 0.3 0.3 0.1 0.3 0.2
1.57 0.87 -0.11 1.11 1.97 1.08 1.99 0.87 1.58
NS NS NS NS
0.4 2 0.5 0.9 * 0.9
0.7 0.5 0.3 0.5 0.4 30.2
k 2 k r -c
0.8 0.8 0.6 0.5 0.5
2 21.1
0.7 e 0.6
20.8
t + k + + + + -t 2
0.7 0.7 0.7 0.8 0.5 0.4 0.2 0.4 0.3
+ 18.8
0.4 + 0.6
1.48
1.48
<0.05 NS
<0.05 NS NS NS NS
*Mean f standard deviation. NS = not significant.
TABLE Ill Comparison Illness for Early Versus Subscale
of the Psychosocial Adjustment to Late Arrivers at Three-Month Follow-Up Early Arrivers*
Late Arrivers*
13.5 * 4.2
10.9 * 5.4
2.12
0.04
8.7 t 2.7
1.90
0.06
Health care orientation Vocational environment Domestic environment Sexual relations Extended family Social environment Psychological distress
10.0 k 2 14.4 2 3.1
10.0 z!z 2.6 6.8 2 2.2 9.3 -c 2.1 11.7? 3.2
11.6 + 4.2
8.4 5.4 7.9 9.3
-t + + r
4.3 3.1 3 4.2
t
p Value
2.92
0.006
1.98 2.36 2.36 2.69
0.05 0.02 0.02 0.01
*Mean ? standard deviation. -I
diovascular disease were subsequently found. Conse quently, the psychosocial differences that were found cannot be easily explained by differences in demographics, ventricular function or disease severity. This outcome could be an unexpected effect of thrombolytic treatment rather than of early arrival. To test this hypothesis, we compared the 7 scales of the Psychosocial Adjustment to Illness Scale of the 8 patients who did not receive thrombolytic therapy, despite arriving early enough to the emergency department to be eligible, with the scores of the 17 who did receive it. There were no differences on any of the 7 scales. In fact, the means were nearly identical (p >0.60). Thus, poorer psychosocial adjustment appears to be associated with relatively early arrival at the emergency department and not with thrombolytic therapy. It is possible that the patients who arrived early may have done so in part because they were more anxious than were the later arrivers after the onset of AMI. However, it is possible that the early arrivers became more anxious after their hospital admission for reasons that are currently unclear. In any case, there may be reason to be concerned. Previous studies have documented increased mortality and both medical and psychological morbidity in anxious, depressed or stressed patients with a recent AMI.13-16 If anxiety or other forms of emotional distress are detected in early arrivers, these patients may need psychological treatment afADJUSTMENT
AFTER
ACUTE
MYOCARDIAL
INFARCTION
161
ter they are medically stabilized. If their anxiety were treated after admission, both the long-term medical and psychosocial prognosis of these patients may be improved. There is already evidence that such an intervention may have a beneficial effect. Frasure-Smith and PrinceI randomly assigned patients after AM1 to either standard care or standard care plus, a stress reduction intervention. After 1 year, these patients had lower stress scores and fewer cardiac deaths than did control subjects. Earlier studies documented other psychological differences between late and early arrivers to the emergency department after the onset of AMI. Theorell et all8 found that the inability to relax during leisure time (an aspect of the type A behavior pattern) was associated with a shorter delay in arrival. However, Matthews et alI9 found that patients who delayed in deciding that they were ill after onset of symptoms tended to exhibit type A behavior. Patients who delayed seeking treatment after deciding they were ill tended to exhibit type B behavior. We did not find differences between our early and late arrivers on our type A measure. Matthews used the Structured Interview to assessthe type A behavior pattern, whereas we used the Jenkins Activity Survey self-report inventory. The Interview may be more sensitive than the Jenkins scale to the relevant type A features. Although denial was not assessedin this study, it is possible that patients who arrived late were less anxious than early arrivers, because they were denying the seriousness or even the reality of their AMI. However, Hackett and Cassem*O did not find a relation between denial and time of arrival to the emergency department in patients with AMI. They found that other factors (such as another person insisting that the patient go to the emergency department) played a more important role. Many patients engage in some form of denial after AMI, and this denial is usually associated with reduced anxiety while in the cardiac care unit.*] Levine et al** found that patients who strongly denied their illness tended to spend fewer days in the cardiac care unit and had fewer signs of cardiac dysfunction during hospitalization. However, in the year after hospital discharge, strong deniers adapted more poorly. Our late arrivers, however, continued to do well 3 months after discharge. The role of denial in late arrival needs further investigation. In conclusion, this study found that patients who arrived at the hospital early after onset of symptoms were more anxious during hospitalization and had a worse psychosocial adjustment in the 3 months after AMI. Psychotherapeutic intervention may be useful in these patients, because studies have shown that high levels of anxiety after AM1 are associated with a poor medical prognosis and worse psychosocial adjustment. In addition, further research is needed to develop strategies
162
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
that encourage early hospital admission without unnecessarily increasing anxiety. Unfortunately, the conclusion of Hackett and Cassem*l nearly 25 years ago still applies today: “. . . we know almost nothing about the social, psychological, or genetic factors that facilitate or inhibit the process of delay. . . .” Further research with larger samples of patients is clearly needed to delineate the psychological and social determinants of the decision to go to the emergency department when symptoms of AM1 occur, and to understand the factors affecting the psychosocial adjustment of early arrivers.
REFERENCES
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JANUARY
15, 1992