Maximizing recovery after cardiac events

Heart attack survivors may do quite well after discharge, only to face difficulties returning to work, continuing rehabilitation, or other barriers to recovery.

Roughly 735,000 Americans have a heart attack each year—some with a related cardiac arrest—including 525,000 for the first time, according to American Heart Association data. Some recent studies, by measuring quality of life and other effects, are striving to provide better insights into how well these patients navigate their postrecovery lives.

One study, published in 2016 in the Journal of the American College of Cardiology, provided encouraging news for patients who survive and out-of-hospital cardiac arrest and are discharged from the hospital (and not to hospice). The mortality rate during the subsequent first year was similar for those who had experienced a cardiac arrest along with a myocardial infarction (MI) compared with an MI alone—13.8% versus 15.8% for the latter group, according to data from 54,860 patients ages 65 years and older.

“We were actually surprised that we found that in fact the patients with cardiac arrest, once we get them through the hospital, those who survive actually do quite well relatively speaking,” said Christopher Fordyce, MD, a clinical assistant professor in the division of cardiology at the University of British Columbia in Vancouver.

But another key milestone, returning to work, has been more difficult for cardiac arrest survivors to reach, according to a study involving European patients that was published in January in Circulation: Cardiovascular Quality and Outcomes.

Among those individuals who survived a cardiac arrest, 46.5% returned to their prior level of work. An additional 22.5% also resumed employment, albeit at reduced hours. But a matched group of heart attack survivors fared better; 72% returned to their prior work lives and another 8% did so but at reduced hours.

In addition, a recent study published June 12 by Circulation: Cardiovascular Quality and Outcomes looked at 9,319 patients who had had an MI and found that those who had more unplanned admissions, postdischarge bleeding complications, hypertension, and smoking were more likely to have an adverse change in employment at one year. This group was more likely to be depressed, to have lower health status, and to report moderate to extreme financial hardship in medication costs, the study authors found.

Job-related insights

Better understanding patients' heart recovery trajectory, and whether it differs between genders, has been one of the focuses of Yale University researcher Rachel Dreyer, PhD.

An MI is a life-changing event, said Dr. Dreyer, an assistant professor in the department of emergency medicine at Yale who coauthored an editorial accompanying the Circulation: Cardiovascular Quality and Outcomes study. “It's accompanied by a complex set of emotional reactions that can pose barriers to successful recovery and functioning and their ability to resume employment.

In one of Dr. Dreyer's own studies, she and her colleagues looked at the likelihood of younger heart attack patients, ages 18 to 55 years, returning to work. The men in the group of 1,680 patients were slightly more likely, 89%, versus 85% among the women, according to the findings, which were published in 2016 in Circulation: Cardiovascular Quality and Outcomes.

The difference didn't prove to be statistically significant after adjustment for socioeconomics, health status, and other factors. Still, Dr. Dreyer wants to learn more about the 14% overall of men and women who did leave the workforce. What physical and other factors led them to drop out?

Dr. Dreyer and her colleagues did flag a few patterns. Those who didn't return to work were less likely to be married and more likely to work a manual job and enjoy less robust health prior to their heart attack. Women specifically may be coping with symptoms that might make it more difficult to work, said Dr. Dreyer, citing a prior 2015 study she was involved with, published in Circulation.

That study, which relied on the same dataset of younger heart attack patients, looked at symptoms and quality of life during the first post-MI year. Researchers found that women experienced more physical and mental symptoms and reported more angina and generally a lower quality of life than their male counterparts.

Cardiac rehab gaps

During those first few months after a scary heart crisis, cardiac rehabilitation sessions can help bolster patients mentally as well as physically, said Kelsey Flint, MD, a cardiologist and an assistant professor of medicine at the VA Eastern Colorado Health Care System in Denver.

“Patients often feel very timid in every aspect of their life afterward,” Dr. Flint said. “Speaking more from anecdotal experience, I find that cardiac rehab really helps patients regain their confidence after a big event such as a heart attack.”

But Dr. Flint worries that too often more frail patients might be unnecessarily missing out. She was the lead author on an observational study, published Feb. 24 in the Journal of the American Heart Association, that looked at death and disability after one year among 329 patients ages 65 years and older.

Those with slower gait speeds got the same benefits from cardiac rehabilitation as those who were able to walk faster. (The speed, assessed during a prior study based on a home assessment, translated to less than 1.8 miles per hour, roughly similar to someone “slowly making it around their house,” Dr. Flint said.) But the slower walkers reported they had been less likely to have been encouraged to participate—55.7% versus 68.9% for those with faster gaits.

In the end, only 27.1% of those individuals with slow gaits joined the rehab sessions versus 40.1% of the faster walkers. “The implication there is that we, meaning cardiology and primary care providers, should still consider encouraging patients to participate in cardiac rehab even if we perceive them to be frail,” Dr. Flint said.

The study also highlighted other potential socioeconomic vulnerabilities, Dr. Flint noted. Those older individuals with slow gait speeds who didn't enroll in cardiac rehab were more likely to be female, nonwhite, unmarried, and less educated.

Unseen stressors

With those social factors in mind, doctors should look out for sometimes hidden barriers to recovery, Dr. Flint said. Figure out if the rehabilitation facility's location is too far away, or the patient lacks a way to get there, she said. Get a key family member involved in the patient's recovery by joining appointments, even if it's only by speakerphone for those unable to break away from work or another commitment.

When a patient lobbies to return to work, and the job involves manual labor, Dr. Flint pushes even more fiercely for cardiac rehabilitation first, so the strain of exertion can be monitored in a controlled setting. “Because then cardiac rehab nurses and physiologists can give me feedback on how the patient is doing,” she said.

Meanwhile, depression, anxiety, and other mental health struggles can inhibit recovery in ways that are still being understood. One recent study involving nearly 25,000 U.S. patients diagnosed with a heart attack or angina looked at mortality rates for those subsequently diagnosed with depression. During a follow-up period of nearly a decade, 50% of those with depression died compared with 38% without, according to the 2017 study published in European Heart Journal: Quality of Care & Clinical Outcomes.

Anthony Pavlo, PhD, a clinical psychologist at Yale who is working with Dr. Dreyer on her cardiovascular research, said that heart attack survivors might be coping with everything from a feeling of health vulnerability and concerns about their sexuality to various forms of self-blame that can inhibit their recovery. Did they work too hard? Was their poor diet the culprit?

Meanwhile, Dr. Pavlo said, “The sort of care that they're given afterwards [by clinicians] is all focused on those things that they might be blaming themselves for.” And, he added, “No one is really saying, ‘Well, how are you doing with all of this?’”

One approach is for physicians to pose open-ended questions to gauge the patient's state of mind, Dr. Pavlo said, such as “What's going on? What are you most worried about these days?”

Above all, physicians should keep their radar attuned to why a patient may appear to be nonadherent to rehab or therapy after a cardiac event, because there is frequently something else going on, Dr. Pavlo said.

Even if patients don't meet diagnostic criteria for depression or another mental health issue, they may be walking around demoralized and even subconsciously braced for that next heart crisis, he said. “If someone is not feeling hopeful, they are not going to go to cardiac rehab. What's the point?”

Instead of just handing over a depression screen, Dr. Pavlo said, the doctor can provide some broader context. “You can say, ‘Often people might get depressed after a heart attack. It is a life-changing event and that's why we're doing this screen.’ It doesn't take a lot of time [to say], and people get it.”