This study investigated the likelihood of psychosocial distress after spontaneous coronary artery dissection (SCAD) compared with traditional heart attack. Post-event anxiety, depression, and distress were more common in patients with SCAD than in patients without SCAD. The findings highlight the need for increased psychosocial support after SCAD-AMI.
Keywords: anxiety, depression, distress, information provision, psychocardiology, SCAD, secondary prevention, stress
Abstract
Purpose:
Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute myocardial infarction (AMI), particularly in younger women without classic cardiac risk factors. Spontaneous coronary artery dissection is considered to be particularly stressful; however, few studies have quantified SCAD survivor stress levels. This study compared anxiety, depression, and distress levels in SCAD and non-SCAD AMI patients.
Method:
A sample of 162 AMI (35 [22%] SCAD) patients was recruited from hospitals and via social media, in Australia and the United States. All had had their AMI in the past 6 mo. Participants completed an online questionnaire comprising the Generalized Anxiety Disorder-2 (GAD2), Patient Health Questionnaire-2 (PHQ2), Kessler-6 (K6), and Cardiac Distress Inventory (CDI). T-tests, χ2 tests, Mann-Whitney tests, and analysis of covariance were used to compare SCAD and non-SCAD samples. Logistic regression was used to identify the unique predictors of anxiety, depression, and distress, controlling for relevant confounders.
Results:
Patients with SCAD were more commonly female and significantly younger than non-SCAD patients. Patients with SCAD scored significantly higher on the GAD2, PHQ2, K6, and CDI and a significantly larger proportion was classified as anxious, depressed, or distressed using these instruments. In logistic regression, together with mental health history, having had a SCAD-AMI predicted anxiety, depression, and distress, after controlling for female sex, younger age, and other confounding variables.
Conclusion:
This study supports the view that anxiety, depression, and distress are more common after SCAD-AMI than after traditional AMI. These findings highlight the psychosocial impacts of SCAD and suggest that psychological support should be an important component of cardiac rehabilitation for these patients.
KEY PERSPECTIVE
What is novel?
Emerging evidence suggests that spontaneous coronary artery dissection (SCAD) is a particularly stressful type of acute myocardial infarction (AMI). However, few studies have compared the prevalence of anxiety and depression in patients with typical atherosclerotic AMI and those with SCAD-AMI. This study is particularly novel in that it compares rates of anxiety, depression, and distress in patients with typical AMI and those with SCAD-AMI, and identifies the unique predictors of anxiety, depression, and distress in these patients. The findings highlight that, even after controlling for other key red flags for post-event mental health problems, having an SCAD-AMI is a unique predictor of anxiety, depression, and distress. Prior mental health history also emerged as a unique predictor of poor post-event mental health.
What are the clinical and research implications?
The study findings suggest an urgent need to develop and trial psychosocial interventions for survivors of SCAD to support their psychological recovery and improve their long-term prognosis.
Increasing research attention is being paid to the psychosocial consequences of spontaneous coronary artery dissection (SCAD), a cause of acute myocardial infarction (AMI) that is particularly common in young women with few classic cardiac risk factors.1–4 Spontaneous coronary artery dissection accounts for up to 35% of AMIs in women aged < 50 yr,3,4 and is the most common cause of pregnancy-related AMI.5,6 Unlike typical AMI, which is generally due to atherosclerosis, SCAD-AMI is nonatherosclerotic and occurs when a coronary vessel develops a hematoma within the arterial wall, which bulges inward obstructing blood flow to the heart.3 Hospital readmission and recurrence are more common post-SCAD than following typical AMI.7–10
Studies suggest high levels of anxiety, depression, and stress in survivors of SCAD.11–15 Indeed, emotional stress is often reported as the precipitating trigger for the acute SCAD event.3,6,9,11,16–18 Uncertainty and lack of information provision surrounding the diagnosis and optimal management, and the likelihood of recurrence, contribute to the psychosocial sequelae of SCAD.11,19 Emerging evidence therefore suggests that SCAD may be more stressful than typical AMI.
However, very few studies have been undertaken to compare rates of post-event mental health conditions in patients with SCAD versus patients with atherosclerotic AMI. One early study demonstrated that survivors of SCAD have higher levels of anxiety, depression and distress than those who have typical atherosclerotic AMI.13 However, a more recent study found that SCAD survivors' rates of depression and stress were no different to those seen in patients with typical atherosclerotic AMI.20,21 More studies are needed to fully understand the comparative rates of anxiety, depression, and distress in AMI patients with and without SCAD to facilitate the development of more tailored supports for this relatively underresearched and poorly understood group.3,4
Several patient-related factors have been shown to increase anxiety and depression risk after typical AMI, and these need to be considered in investigations of the psychosocial impacts of SCAD. A history of anxiety or depression is a known risk factor or “red flag” for poor post-event mental health,22–24 as is being younger at the time of the event, particularly being of pre-retirement age.22,23,25,26 Low socioeconomic status and financial strain, indicated by factors such as not having private health insurance and not being a home owner, also predict poor post-event mental health.22,23,27,28 In Australia, having private health insurance is associated with outright home ownership, luxury vehicle ownership, and a six-figure income,29 hence its relevance as an indicator of financial security. Other known red flags include social isolation, indicated by living alone or self-reported loneliness22,23,27,30 and having diabetes.22,23,31 Attendance at cardiac rehabilitation (CR) has been shown to ameliorate post-event anxiety and depression risk, providing a protective effect.30 Finally, given that SCAD is more likely in women,3,4,20 who as a group have a tendency toward higher distress,15,22,32,33 patient sex also needs to be taken into account when attributing post-event mental health problems to the SCAD event.
The aims of the present study were twofold: first, to report and compare rates of anxiety, depression, and distress in AMI patients with and without SCAD, while accounting for relevant covariates; and second, to determine whether having had a SCAD was a unique predictor of anxiety, depression, and distress in AMI patients after controlling for other known predictors of poor mental health post-AMI.
METHODS
This study had ethics approval from the Monash Health Human Research Ethics Committee (approval number: RES-19-0000631A—55979) and the Stanford University Institutional Review Board. Eligible participants were those who have had an AMI in the previous 6 mo. Patients who did not have adequate English language proficiency to read and understand the consent form and questionnaire were excluded.
Two samples of patients were recruited. One was a sample of patients with AMI consecutively admitted to two hospitals in Melbourne, Australia, over an 8-mo period. The other was a convenience sample of AMI survivors recruited from CR programs, general practice settings, and social media following promotion of the study by the Australian Centre for Heart Health, with assistance from Stanford University (United States) and Heart Support Australia. Participants in the hospital sample were recruited during their hospital stay and were recontacted at approximately 8-wk post-discharge and invited to complete the questionnaire. Participants in the convenience sample were required to have had their event within the past 6 mo and were invited to complete the questionnaire as soon as possible. The sample was recruited as part of a larger international study of cardiac-related emotions that was open to people who had experienced a broad range of cardiac events.34–36 The present study was limited to those who had had an AMI within the past 6 mo.
Questionnaires were completed either in hard copy or online via the Research Electronic Data Capture (REDCap) platform. All participants were directed to the website of the Australian Centre for Heart Health to use an online link to the REDCap questionnaire or to request a hard copy of the questionnaire for completion at home and return in a reply-paid envelope. The questionnaire took approximately 25 min to complete. No identifying information was collected as no participant follow-up was involved.
MEASURES
Anxiety, Depression, and Distress
The Generalized Anxiety Disorder-2 (GAD2)37 questionnaire is a validated brief screen for anxiety, comprising two items from the GAD7. The Patient Health Questionnaire 2-item (PHQ2)38 is a validated brief screen for depression, comprising two items from the PHQ9. Total scores for both the GAD2 and the PHQ2 range from 0-6, with scores ≥3 indicative of probable clinical anxiety or depression, respectively.37,38 The GAD2 and the PHQ2 have been used previously to assess rates of anxiety and depression in cardiac samples.39,40 The Kessler Psychological Distress Scale-6 (K6)41 is a validated brief measure of psychological distress. Scores range from 0-24, with scores ≥13 indicative of high distress.41 The Cardiac Distress Inventory (CDI) is a 55-item measure of cardiac distress, which gives an indication of the nature and level of cardiac-related distress experienced in the past 4 wk.35,36 The CDI comprises eight domains addressing fear and uncertainty, disconnection, overwhelm, death concerns, impacts on roles and relationships, cognitive challenges, physical health challenges, and health system challenges. The CDI-Short Form (CDI-SF) comprises 12 items from the CDI, with scores ≥13 indicative of high cardiac distress.42
Sociodemographic and Clinical Questions
Questions regarding sociodemographic and clinical characteristics were also included. Sociodemographic information included sex, age, partner status (partnered/unpartnered), living arrangements (live alone/live with others), employment status, education, private health insurance (yes/no [Y/N]), presence of a close confidante (Y/N), and loss of a close relative or friend in the past 12 mo (Y/N; defined as “recent bereavement”). Clinical information included event type (SCAD AMI/non-SCAD AMI), cardiovascular risk factors (high blood pressure, high cholesterol, diabetes, obesity, and sleep apnea), significant comorbidity (musculoskeletal conditions, thyroid conditions, heart failure, stroke, respiratory, and kidney conditions), and CR attendance status (Y/N). Participants also self-reported on whether they had current mental health conditions, namely anxiety (Y/N) and depression (Y/N), or a history of a mental health condition prior to the cardiac event, namely history of anxiety (Y/N) and history of depression (Y/N).
DATA ANALYSIS
The sociodemographic and clinical characteristics of SCAD-AMI and non-SCAD-AMI samples were compared using χ2 tests (for categorical variables) and t tests (for continuous variables). Benjamini-Hochberg adjusted P values were calculated to control for type 1 error due to multiple comparisons. In comparing SCAD-AMI and non-SCAD-AMI samples on measures of anxiety, depression, and distress, both mean scale scores and categorical prevalence ratings were considered. To compare mean scale scores, Mann-Whitney tests were used due to the nonnormal distribution of scale scores. In addition, analysis of covariance (ANCOVA) was used to control for the effects of a priori identified confounders, namely female sex, age < 60 yr, mental health history, living alone, not having health insurance, having diabetes, and CR nonattendance. All these variables were entered as covariates. To compare categorical prevalence ratings using relevant clinical cut-offs (GAD2 ≥ 3 for anxiety; PHQ2 ≥ 3 for depression; K6 ≥ 6 for distress; and CDI-SF ≥ 13 for cardiac distress), χ2 tests were used. To control for the effects of a priori identified confounders, multivariate logistic regression was used to identify the unique predictors of anxiety, depression, distress, and cardiac distress, while controlling for female sex, age < 60 yr, mental health history, living alone, not having health insurance, having diabetes, and CR nonattendance.
RESULTS
A total of 162 AMI patients was recruited, with 35 (22%) patients with SCAD and 127 (78%) patients without SCAD. Most (139 [86%]) resided in Australia, with 23 (14%) from North America. Two thirds (109 [67%]) were recruited through participating hospitals, and one third (53 [33%]) through convenience sampling. Patients with SCAD were more likely to be recruited through convenience sampling (27 [77%]), whereas patients without SCAD were more likely to be recruited through participating hospitals (101 [79%]) (χ2 = 40.03, P < .001). The convenience sample comprised respondents who were significantly younger than hospital patients (59.4 ± 13.5 vs 63.8 ± 10.9 yr, respectively; F = 4.85, P < .029) and more likely female (79 vs 30%; χ2 = 34.31, P < .001). Importantly, there were no differences in rates of anxiety, depression, or distress in patients with SCAD recruited via the two different sampling methods (χ2 = 0.65, P = .418, for PHQ2; χ2 = 2.90, P = .089, for GAD2; χ2 = 0.39, P = .529, for K6; χ2 = 2.19, P = .139, for CDI-SF).
DIFFERENCES BETWEEN PATIENTS WITH AND WITHOUT SCAD IN SELF-REPORTED SOCIODEMOGRAPHIC AND CLINICAL CHARACTERISTICS
The age of patients overall was 62.3 ± 11.9 yr, with patients with SCAD significantly younger than patients without SCAD (53.7 ± 10.6 vs 64.7 ± 22.73 yr; F = 27.32, P < .001). Due to patients with SCAD being more likely recruited via the convenience sample, the time since the acute AMI event was on average 1 mo longer for patients with than without SCAD (3.0 ± 2.0 vs 2.0 ± 1.3 mo; F = 13.33, P < .001). Other characteristics of SCAD and non-SCAD samples are shown in Table 1.
Table 1. Baseline Sociodemographic and Clinical Characteristicsa.
| Characteristics | SCAD n = 35 |
Non-SCAD n = 127 |
Total n = 162 |
χ 2 | P Value |
|---|---|---|---|---|---|
| Sociodemographic | |||||
| Sex, female | 33 (94.3) | 42 (33.1) | 75 (46.3) | 41.34 | <.001b |
| Age, <60 yrc | 26 (74.3d) | 44 (34.9) | 70 (43.5) | 17.27 | <.001b |
| Married or partnered | 29 (82.9) | 84 (66.1) | 113 (69.8) | 3.63 | .057 |
| Living alone | 2 (5.7) | 30 (23.8) | 32 (19.9) | 5.63 | .018b |
| In paid workforce | 25 (71.4) | 64 (50.4) | 89 (54.9) | 4.90 | .027 |
| University education | 22 (62.9) | 37 (29.1) | 59 (36.4) | 13.48 | <.001b |
| Has private health insurancee | 24 (68.6) | 50 (41.3) | 74 (47.4) | 8.08 | .004b |
| Has close confidant | 29 (82.8) | 106 (83.5) | 135 (83.3) | 0.53 | .469 |
| Recently bereavedf | 11 (31.4) | 30 (25.2) | 41 (26.6) | 0.53 | .464 |
| Cardiovascular risk factors | |||||
| High blood pressure | 7 (20.0) | 50 (39.4) | 57 (35.2) | 4.51 | .034 |
| High cholesterol | 4 (11.4) | 44 (34.6) | 48 (29.6) | 7.09 | .008b |
| Diabetes | 1 (2.9) | 35 (27.6) | 36 (22.2) | 9.69 | .002b |
| Obesity | 9 (25.7) | 11 (8.7) | 20 (12.3) | 7.37 | .007b |
| Sleep apnea | 2 (5.7) | 11 (8.7) | 13 (8.0) | 0.32 | .570 |
| Comorbid conditions | |||||
| Musculoskeletal condition | 8 (22.9) | 29 (22.8) | 37 (22.8) | 0.00 | .998 |
| Thyroid condition | 2 (5.7) | 0 (0) | 2 (1.2) | 7.34 | .007b |
| Heart failure | 0 (0.0) | 7 (5.5) | 7 (4.3) | 2.01 | .156 |
| Stroke | 0 (0.0) | 5 (3.9) | 5 (3.1) | 1.42 | .233 |
| Respiratory problems | 1 (2.9) | 9 (7.1) | 10 (6.2) | 0.85 | .357 |
| Kidney problems | 1 (2.9) | 9 (7.1) | 10 (6.2) | 0.85 | .357 |
| Current mental health problems | |||||
| Self-reported anxiety | 12 (34.3) | 21 (16.5) | 33 (20.4) | 5.33 | .021b |
| Self-reported depression | 13 (37.1) | 22 (17.3) | 35 (21.6) | 6.36 | .012b |
| Mental health history | |||||
| History of anxiety | 17 (48.6) | 22 (17.3) | 39 (24.1) | 14.66 | <.001b |
| History of depression | 14 (40.0) | 29 (22.8) | 43 (26.5) | 4.15 | .042 |
| History of any mental health condition | 20 (57.1) | 40 (31.5) | 60 (37.0) | 7.74 | .005b |
| Other | |||||
| Attended cardiac rehabilitationg | 20 (57.1) | 60 (50.4) | 80 (51.9) | 0.49 | .484 |
Abbreviations: CDI, Cardiac Distress Inventory 55-item; CDI-SF, Cardiac Distress Inventory Short Form (12-item); GAD2, Generalized Anxiety Disorder 2-item; K6, Kessler 6-item; non-SCAD, traditional acute myocardial infarction; PHQ2, Patient Health Questionnaire 2-item; SCAD, spontaneous coronary artery dissection.
aData presented as n (%). Statistical test =χ2. df = 1 for all tests. Significance level set at P < .027 after Benjamini-Hochberg adjustment.
bIndicates significant comparisons.
cn = 126 for non-SCAD, n = 161 for total.
dItalicized indicates significantly higher proportions.
en = 121 for non-SCAD, n = 156 for total.
fHaving lost of relative or friend in the past 12 mo.
gn = 119 for non-SCAD, n = 154 for total.
In terms of sociodemographic characteristics, patients with SCAD-AMI were significantly more likely than non-SCAD AMI patients to be female, aged <60 yr, university educated, to live with others, and to have private health insurance. There were no differences between the two groups in the proportions who were married/partnered, in the paid workforce, had a close confidant, or had experienced a recent bereavement.
In terms of cardiovascular risk factors, patients with SCAD were significantly less likely than patients without SCAD to report having high cholesterol or diabetes, and significantly more likely to report having obesity. In terms of comorbid physical health conditions, patients with SCAD were more likely than patients without SCAD to report having a thyroid condition. Unlike patients without SCAD, no patients with SCAD reported having heart failure or stroke, and few had respiratory or kidney conditions; however, comparisons did not reach statistical significance due to the low prevalence of these conditions overall. In terms of self-reported current and past mental health problems, patients with SCAD were significantly more likely than patients without SCAD to self-report experiencing current and past anxiety, and current but not past depression. The two samples did not differ in CR attendance rates.
DIFFERENCES BETWEEN PATIENTS WITH AND WITHOUT SCAD IN MEAN SCALE SCORES ON MEASURES OF ANXIETY, DEPRESSION, DISTRESS, AND CARDIAC DISTRESS
Mean scores on the GAD2, PHQ2, K6, CDI, CDI-SF, and the CDI domains are shown for patients with and without SCAD in Table 2. As shown, patients with SCAD scored significantly higher than their counterparts without SCAD on the GAD2, PHQ2, K6, CDI, and CDI-SF, and on all eight CDI domains. After controlling for relevant confounders, these differences remained significant for the K6, the CDI, and the CDI-SF, and approached significance for the GAD2. However, for the PHQ2, the difference was no longer significant. In terms of CDI domains, after controlling for confounders, the differences remained significant for the domains of fear and uncertainty, overwhelm, roles and relationships, and health system challenges, and approached significance for cognitive challenges. The differences were no longer significant for the domains of disconnection, death concerns, and physical health challenges.
Table 2. Differences in Scores on the PHQ2, GAD2, K6, and CDI for Patients With and Without SCADa.
| Instrument | SCAD n = 35 |
Non-SCAD n = 127 |
Total n = 162 |
Unadjusted | Adjustedb | ||
|---|---|---|---|---|---|---|---|
| z | P Value | F | P Value | ||||
| Scale scores | |||||||
| GAD2 | 2.71c± 1.7 | 1.27 ± 1.38 | 1.60 ± 1.58 | 4.59 | <.001 | 3.61 | .059 |
| PHQ2 | 2.00 ± 1.78 | 1.22 ± 1.48 | 1.39 ± 1.58 | 2.49 | .013 | 0.59 | .445 |
| K6 | 14.94 ± 5.17 | 11.06 ± 4.50 | 11.92 ± 4.92 | 3.94 | <.001 | 4.83 | .030 |
| CDI | 48.04 ± 26.38 | 25.69 ± 21.81 | 30.52 ± 24.59 | 4.55 | <.001 | 5.88 | .016 |
| CDI-SF | 12.89 ± 7.23 | 7.05 ± 6.41 | 8.31 ± 7.00 | 4.29 | <.001 | 5.53 | .020 |
| Domains of the CDI | |||||||
| Fear and uncertainty | 38.45 ± 23.85 | 20.07 ± 18.05 | 24.04 ± 20.80 | 4.17 | <.001 | 4.22 | .037 |
| Disconnection | 17.86 ± 17.20 | 9.78 ± 15.47 | 11.53 ± 16.16 | 3.30 | .001 | 0.67 | .412 |
| Overwhelm | 40.54 ± 22.02 | 19.83 ± 18.33 | 24.31 ± 20.94 | 4.82 | <.001 | 10.58 | .001 |
| Death concerns | 40.47 ± 29.30 | 21.71 ± 24.24 | 25.77 ± 26.48 | 3.48 | <.001 | 2.27 | .134 |
| Roles and relationships | 24.16 ± 19.04 | 12.23 ± 14.69 | 14.81 ± 16.42 | 3.76 | <.001 | 4.14 | .044 |
| Cognitive challenges | 30.71 ± 26.33 | 15.73 ± 21.96 | 18.96 ± 23.71 | 3.67 | <.001 | 3.11 | .080 |
| Physical health challenges | 27.62 ± 15.59 | 19.96 ± 16.74 | 21.62 ± 16.71 | 2.74 | .006 | 0.35 | .553 |
| Health system challenges | 19.43 ± 23.17 | 6.98 ± 12.51 | 9.67 ± 16.19 | 3.55 | <.001 | 6.29 | .013 |
Abbreviations: CDI, Cardiac Distress Inventory 55-item; CDI-SF, Cardiac Distress Inventory Short Form (12-item); GAD2, Generalized Anxiety Disorder 2-item; K6, Kessler 6-item; non-SCAD, traditional acute myocardial infarction; PHQ2, Patient Health Questionnaire 2-item; SCAD, spontaneous coronary artery dissection.
aData presented as mean ± SD. Statistical test = Mann-Whitney test. df = 1 for all tests. Significance level set at P < .05.
bStatistical test = ANCOVA adjusting for female sex, aged < 60, mental health history, living alone, diabetes, no health insurance, and not attend cardiac rehabilitation program. n = 35 for SCAD, n = 119-127 for non-SCAD.
cItalicized indicates significantly higher mean scores.
DIFFERENCES BETWEEN SCAD AND NON-SCAD PATIENTS IN PREVALENCE OF ANXIETY, DEPRESSION, DISTRESS, AND CARDIAC DISTRESS USING CLINICAL CUT-OFFS
Prevalence rates of anxiety, depression, distress, and cardiac distress based on recommended clinical cut-offs on the GAD2, PHQ2, K6, and CDI-SF are shown in Table 3. As shown, patients with SCAD were significantly more likely than patients without SCAD to be categorized as having probable anxiety, depression, distress, and cardiac distress using the GAD2, PHQ2, K6, and CDI-SF cut-offs, respectively.
Table 3. Proportions of Patients With and Without SCAD Classified as Anxious, Depressed, or Distressed Using the GAD2, PHQ2, K6, and CDI-SFa.
| Characteristics | SCAD n = 35 |
Non-SCAD n = 127 |
Total n = 162 |
χ 2 | P Value |
|---|---|---|---|---|---|
| Anxious (GAD2) | 18 (51.4b) | 16 (13.3) | 34 (21.9) | 22.96 | <.001 |
| Depressed (PHQ2) | 13 (37.1) | 17 (14.3) | 30 (19.5) | 9.01 | .003 |
| Distressed (K6) | 12 (34.3) | 9 (7.1) | 21 (13.0) | 17.19 | <.001 |
| Cardiac distressed (CDI-SF) | 17 (48.6) | 22 (17.3) | 39 (24.1) | 14.66 | <.001 |
Abbreviations: CDI-SF, Cardiac Distress Inventory Short Form (12-item); GAD2, Generalized Anxiety Disorder 2-item; K6, Kessler 6-item; non-SCAD, traditional acute myocardial infarction; PHQ, Patient Health Questionnaire 2-item; SCAD, spontaneous coronary artery dissection.
aData presented as n (%). Anxious = GAD2 ≥ 3; depressed = PHQ2 ≥ 3; distressed = K6 ≥ 13; cardiac distressed = CDI-SF ≥ 13. Statistical test =χ2 test. df = 1 for all tests. Significance level set at P < .05.
bItalicized indicates significantly higher proportions.
PREDICTORS OF ANXIETY, DEPRESSION, DISTRESS, AND CARDIAC DISTRESS
Results of the logistic regression analyses are shown in Table 4. After controlling for a priori identified confounders, having an SCAD emerged as a significant predictor of anxiety, depression, distress, and cardiac distress. Notably, having a mental health history also emerged as a significant predictor of each outcome.
Table 4. Results of Logistic Regression to Predict Anxiety, Depression, Distress, and Cardiac Distressa.
| OR | 95% CI | P Value | |
|---|---|---|---|
| Predictors of anxiety (GAD2) | |||
| SCAD-AMI | 4.75 | 1.48-15.21 | .009 |
| Mental health history | 4.36 | 1.69-11.25 | .002 |
| Sex, female | 1.50 | 0.50-4.46 | .468 |
| Age, <60 yr | 1.14 | 0.42-3.06 | .800 |
| Live alone | 0.44 | 0.09-2.24 | .324 |
| No health insurance | 2.10 | 0.80-5.54 | .133 |
| Diabetes | 2.79 | 0.84-9.21 | .093 |
| Not attend CR | 0.45 | 0.17-1.13 | .089 |
| Predictors of depression (PHQ2) | |||
| SCAD-AMI | 3.20 | 1.01-10.11 | .047 |
| Mental health history | 3.59 | 1.45-8.88 | .006 |
| Sex, female | 1.05 | 0.36-3.01 | .936 |
| Age, <60 yr | 1.02 | 0.40-2.63 | .966 |
| Live alone | 1.06 | 0.30-3.78 | .927 |
| No health insurance | 0.77 | 0.30-1.95 | .579 |
| Diabetes | 1.39 | 0.45-4.37 | .567 |
| Not attend CR | 0.64 | 0.26-1.55 | .321 |
| Predictors of distress (K6) | |||
| SCAD-AMI | 4.51 | 1.26-16.21 | .021 |
| Mental health history | 5.52 | 1.76-17.31 | .003 |
| Sex, female | 1.85 | 0.47-7.35 | .381 |
| Age, <60 yr | 0.96 | 0.30-3.06 | .944 |
| Live alone | 1.82 | 0.37-8.92 | .462 |
| No health insurance | 0.71 | 0.24-2.15 | .547 |
| Diabetes | 0.509 | 0.93-2.78 | .436 |
| Not attend CR | 0.713 | 0.24-2.15 | .199 |
| Predictors of cardiac distress (CDI-SF) | |||
| SCAD-AMI | 3.19 | 1.10-9.24 | .033 |
| Mental health history | 3.82 | 1.68-8.69 | .001 |
| Sex, female | 1.94 | 0.75-5.13 | .168 |
| Age, < 60 yr | 0.75 | 0.30-1.88 | .539 |
| Live alone | 0.70 | 0.21-2.27 | .550 |
| No health insurance | 1.43 | 0.62-3.33 | .404 |
| Diabetes | 2.35 | 0.84-6.64 | .106 |
| Not attend CR | 0.68 | 0.30-1.54 | .352 |
Abbreviations: AMI, acute myocardial infarction; CDI-SF, Cardiac Distress Inventory Short Form; CR, cardiac rehabilitation; GAD2, Generalized Anxiety Disorder 2-item; K6, Kessler 6-item; PHQ2, Patient Health Questionnaire 2-item; SCAD, spontaneous coronary artery dissection.
aAnxiety = GAD2 ≥ 3; depression = PHQ2 ≥ 3; distress = K6 ≥ 13; cardiac distress = CDI-SF ≥ 13. n = 35 for SCAD, n = 119-127 for non-SCAD. Statistical test = logistic regression. Significance level set at P < .05.
DISCUSSION
The findings of the present study suggest that survivors of SCAD-AMI are more likely than their counterparts without SCAD to experience anxiety, depression, distress, and cardiac distress in the 6 mo after their acute event. Importantly, SCAD-AMI remained as a unique predictor of these psychological states even after controlling for previously identified red flags for poor post-event mental health status, namely female sex, younger age, mental health history, social isolation, socioeconomic disadvantage, diabetes, and nonattendance at CR using logistic regression.22,23,25–28,30–33 Therefore, the current findings confirm that the emotional difficulty associated with SCAD cannot be attributed simply to the fact that most patients with SCAD are younger females, or to their increased likelihood of having a mental health history. Of note, though, the findings regarding post-SCAD depression were not retained after multivariate adjustment using ANCOVA. Qualitative investigations with survivors of SCAD similarly suggest that anxiety and distress are more prominent and pressing issues than is depression,19 supporting this finding. Not surprisingly, having a mental health history emerged as a highly significant predictor of all outcomes, as is typically seen in non-SCAD AMI samples.22–24
The current study is one of the first to assess the relative prevalence of psychological difficulties in AMI patients with and without SCAD. The findings confirm those of an early Canadian study, which similarly demonstrated that survivors of SCAD have higher levels of anxiety, distress, and depression than those who experience a traditional AMI.13 However, a more recent US study found that rates of stress and depression were no different after SCAD than after non-SCAD AMI.21 Importantly, in the latter study, the baseline rates of stress and depression were relatively high even for patients with typical atherosclerotic AMI, at 77% and 33%, respectively,21 which might account for why a difference was not detected.
The rates of anxiety and depression reported here for survivors of SCAD are considerably higher than those seen previously in typical AMI populations. Previous studies of patients with typical atherosclerotic AMI have tended to report anxiety rates of up to 30%22,43–45 and depression rates of around 20%.22,43–46 In contrast, over half the patients with SCAD in the current study were classified as anxious and over a third as depressed. Distress rates varied from over a third for general distress to almost half for cardiac distress.
The rates of anxiety and depression reported here are also somewhat higher than those reported in earlier studies of survivors of SCAD. Studies undertaken in the United States15,47 and the Netherlands48 have reported rates of 12-16% for anxiety and 8-15% for depression. Importantly, the mean time since the acute SCAD was 4.3,47 3.7,15 and 2.5 yr48 in those studies, much later than in the current study where the mean time since SCAD was 3 mo. This delay in assessment likely accounts for the lower rates in the earlier studies, as anxiety and depression symptoms resolve over time.47
Using the recently developed Cardiac Distress Scale,35 patients with SCAD were shown to have high rates of distress across a broad range of cardiac-specific domains. In particular, patients with SCAD reported more fear and uncertainty, and feelings of overwhelm than their counterparts without SCAD. These findings reinforce those from two recent qualitative studies of survivors of SCAD that have highlighted fear and anxiety, uncertainty and confusion, loneliness and isolation, and loss and grief as major challenges faced in the aftermath of SCAD.19,49 Illness uncertainty has been identified as a key challenge in SCAD recovery,19,49 particularly given the rarity, uncertain diagnosis, high recurrence, and unclear management of the condition. The rarity of the condition and the concomitant lack of opportunities to engage with and find support through fellow survivors of SCAD also contributes to SCAD survivors' sense of loneliness and isolation.19 Negative impacts on the roles and relationships of survivors of SCAD were also highlighted, again reinforcing qualitative findings.19,49 Patients with SCAD also scored higher on the domain of health system challenges, which includes items addressing a lack of information, validation, and support (three of the five items ask about “not getting clear directions about managing the condition,” “not getting as much information as I want about my heart condition,” and “not having my concerns taken seriously”).35 This finding underscores how the current lack of knowledge about and understanding of SCAD among health professionals is central to SCAD survivors' challenging recovery process.11,19
Patients with SCAD in the present study were more likely than their counterparts without SCAD to self-report having a history of anxiety or depression, prior to their cardiac event. This is perhaps not surprising, given that emotional stress has been identified as a precipitator of acute SCAD events.3,6,9,11,16,17 This finding questions whether prevention of anxiety and depression could ameliorate the risk of SCAD in people with fibromuscular dysplasia or other indicators of risk, including genetic markers50 or, indeed, the risk of SCAD recurrences in survivors of SCAD. These questions are worthy of attention in future studies.
The cardiovascular risk profile of AMI patients with SCAD in the current study also differed markedly from AMI patients without SCAD, as has been reported elsewhere. Those who had SCAD were less likely than patients with typical atherosclerotic AMI to report having high blood pressure, high cholesterol, or diabetes, consistent with past studies.1–4,10,20,48 While patients with SCAD were more likely than patients without SCAD to report obesity, the prevalence rate of 26% is consistent with previous SCAD studies, which have found obesity in 18% to 27%.10,20,21,51 This rate is also below population rates of 30% in Australia52 and 40% in the United States.53 Indeed, it is possible that the rate of 9% obesity in our non-SCAD sample may represent underreporting.
Patients with SCAD were also more likely to report having a thyroid condition, although the sample size was too small to confirm this finding statistically. Spontaneous coronary artery dissection has been found to be associated with underlying systemic vascular conditions such as fibromuscular dysplasia, connective tissue disorders, migraine headache, and inflammatory disorders,3,6,9,17,18,48,51,54,55 although we did not measure these conditions in the current study.
STUDY LIMITATIONS
Some study limitations should be acknowledged. First, the small number of patients with SCAD limits the study to some extent. Participants were recruited as part of a larger study of emotions in patients across a broad range of cardiac events.35,36 Nonetheless, the findings contribute to our understanding of the psychological consequences of this relatively rare and underresearched condition. Second and related, patients with SCAD were more likely to be recruited via convenience sampling, which may have introduced a self-selection bias into the study. However, there were no differences in rates of anxiety, depression, or distress in patients with SCAD recruited via the two different sampling methods. This suggests that the relatively high rates of anxiety, distress, and depression reported here for patients with SCAD are not due to sampling bias. Third, the GAD2 and the PHQ2 were designed as screening measures rather than diagnostic assessments of anxiety and depression. Importantly, the inclusion of additional measures of distress (the K6 and the CDI), together with these brief measures of anxiety and depression, represents a broad psychological assessment. While the CDI has excellent psychometric properties,35,42 it is only recently developed; thus, these results should be interpreted with some caution. Studies involving translation and validation of the CDI are currently underway in several countries and results will be forthcoming. Fourth, the study relied on self-reporting of key variables, including mental health history, CR attendance, and the SCAD event itself. The study would have been strengthened by verification of SCAD-AMI by either angiogram results or health professional reports, and a more nuanced assessment of CR attendance, to account for CR dose, discontinuation, and completion. Reliance on self-reporting regarding mental health history, while typical in studies of this kind, also potentially limits the reliability of the study findings. As the data were collected as part of a larger study that was not designed specifically as an investigation of patients with SCAD-AMI, data on SCAD-related factors such as migraine, fibromuscular dysplasia, and other connective tissue disorders were not collected. There is a need for carefully designed studies to further investigate the differences between SCAD and non-SCAD AMI to potentially replicate the findings presented here and therefore fine-tune our understanding of the differing mental health needs of these two AMI populations.
CONCLUSION
This study supports the view that patients with SCAD experience more distress, anxiety, and, to a lesser extent, depression than do their AMI counterparts without SCAD, adding to the growing body of knowledge regarding the psychosocial impact of SCAD.11–15,19,49 These findings underscore the importance of providing survivors of SCAD with tailored information and support to assist with their physical and emotional recovery. Previous research has highlighted the need for professionally-facilitated online support programs for SCAD survivors.11,14,19,49 The present findings provide further evidence of the urgent need to better assist survivors of SCAD in their recovery. This could include providing tailored support within existing CR programs, as well as designing SCAD-specific CR programs and other supports. Future studies could investigate the specific support preferences of survivors of SCAD, and trial innovative options for addressing the psychological challenges experienced after SCAD-AMI.
ACKNOWLEDGMENT
We gratefully acknowledge all those who participated in the current study. We also acknowledge the hospital and cardiac rehabilitation program staff who assisted with participant recruitment, particularly those from Barwon Health and Monash Health in Victoria, Australia, and Stanford University in California, the United States. R.M.G., S.E.I., and S.H. were supported in part by NSW Health Cardiovascular Senior Scientist Grants (RG193092 and RG12159) and an NHMRC Investigator Grant (APP2010203).
Footnotes
The authors declare no conflicts of interest.
Contributor Information
Barbara M. Murphy, Email: barbara.murphy@australianhearthealth.org.au.
Michelle C. Rogerson, Email: michelle.rogerson@australianhearthealth.org.au.
Stephanie Hesselson, Email: s.hesselson@victorchang.edu.au.
Siiri E. Iismaa, Email: s.iismaa@victorchang.edu.au.
Valerie Hoover, Email: vhoover@stanford.edu.
Michael Le Grande, Email: michael.legrande@australianhearthealth.org.au.
Robert M. Graham, Email: b.graham@victorchang.edu.au.
Alun C. Jackson, Email: alun.jackson@australianhearthealth.org.au.
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