https://orcid.org/0000-0002-6867-5819
Correction
30 May 2024: Murphy BM, Rogerson MC, Le Grande MR, Hesselson S, Iismaa SE, et al. (2024) Correction: Psychosocial and lifestyle impacts of spontaneous coronary artery dissection: A quantitative study. PLOS ONE 19(5): e0304537. https://doi.org/10.1371/journal.pone.0304537 View correction
Figures
Abstract
Introduction
Recent studies suggest that acute myocardial infarction due to spontaneous coronary artery dissection (SCAD) carries significant psychosocial burden. This survey-based quantitative study builds on our earlier qualitative investigation of the psychosocial impacts of SCAD in Australian SCAD survivors. The study aimed to document the prevalence and predictors of a broad range of psychosocial and lifestyle impacts of SCAD.
Method
Australian SCAD survivors currently enrolled in the Victor Chang Cardiac Research Institute genetics study were invited to participate in an online survey to assess the psychosocial impacts of SCAD. Participants completed a questionnaire, developed using findings from our earlier qualitative research, which assessed 48 psychosocial and five lifestyle impacts of SCAD. Participants also provided demographic and medical data and completed validated measures of anxiety and depression.
Results
Of 433 SCAD survivors invited to participate, 310 (72%) completed the questionnaire. The most common psychosocial impacts were ‘shock about having a heart attack’ (experienced by 87% respondents), ‘worry about having another SCAD’ (81%), ‘concern about triggering another SCAD’ (77%), ‘uncertainty about exercise and physical activity’ (73%) and ‘confusion about safe levels of activity and exertion’ (73.0%) and ‘being overly aware of bodily sensations’ (73%). In terms of lifestyle impacts, the SCAD had impacted on work capacity for almost two thirds of participants, while one in ten had sought financial assistance. The key predictors of psychosocial impacts were being under 50, current financial strain, and trade-level education. The key predictors of lifestyle impacts were being over 50, SCAD recurrence, trade-level education, and current financial strain. All psychosocial impacts and some lifestyle impacts were associated with increased risk of anxiety and/or depression.
Conclusion and implications
This quantitative study extends our previous qualitative investigation by documenting the prevalence of each of 48 psychosocial and five lifestyle impacts identified in our earlier focus group research, and by providing risk factors for greater SCAD impacts. The findings suggest the need for supports to address initial experiences of shock, as well as fears and uncertainties regarding the future, including SCAD recurrence and exercise resumption. Support could be targeted to those with identified risk factors. Strategies to enable SCAD survivors to remain in or return to the paid workforce are also indicated.
Citation: Murphy BM, Rogerson MC, Le Grande MR, Hesselson S, Iismaa SE, Graham RM, et al. (2024) Psychosocial and lifestyle impacts of spontaneous coronary artery dissection: A quantitative study. PLoS ONE 19(1): e0296224. https://doi.org/10.1371/journal.pone.0296224
Editor: Fulvio D’Acquisto, University of Roehampton - Whitelands College, UNITED KINGDOM
Received: October 22, 2023; Accepted: December 7, 2023; Published: January 5, 2024
Copyright: © 2024 Murphy et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Study data are available in the University of Melbourne Figshare repository at https://doi.org/10.26188/24654414.v1. The data underlying this manuscript are subject to conditions of approval obtained by the St Vincent’s Hospital Sydney Human Research Ethics Committee that approved this study. While the data are listed as under embargo, they will be shared on reasonable request provided ethical requirements are met. Data requests should be sent to the St Vincent’s Hospital Sydney Human Research Ethics Committee at the following email address: SVHS.Research@svha.org.au.
Funding: R.M.G., S.E.I., and S.H. were supported in part by NSW Health Cardiovascular Senior Scientist Grants (RG193092 and RG12159; https://www.medicalresearch.nsw.gov.a) and an NHMRC Investigator Grant (APP2010203; https://www.nhmrc.gov.au/funding/find-funding/investigator-grants). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Research into the psychosocial impacts of spontaneous coronary artery dissection (SCAD) has gained increased momentum in recent years. The stressfulness of SCAD-related acute myocardial infarction (AMI) is due to its unexpected occurrence and sudden onset, unclear cause and uncertain management, together with its relatively high recurrence rate [1, 2]. Predominantly affecting younger women without atherosclerosis and with few traditional cardiac risk factors [3–5], SCAD comes as a shock and is not suited to traditional lifestyle management approaches [6, 7]. Emotional stress is often reported as a precipitator to SCAD events [4, 6, 8–11].
Several studies undertaken in the US, Canada, Australia, and Europe have documented relatively high rates of anxiety and depression in the aftermath of SCAD [11–17]. Emerging evidence suggests that SCAD-AMI may be more stressful than typical atherosclerotic AMI, with higher rates of post-event anxiety and depression [13, 17]. However, while previous quantitative studies focus on rates of anxiety, depression and stress, they do not describe the exact nature of specific concerns experienced by SCAD survivors.
To understand the concerns and emotional impacts experienced by SCAD survivors, we undertook and reported on a qualitative study involving 30 SCAD survivors [18]. We found that SCAD survivors experienced a broad range of psychosocial impacts, including confusion and uncertainty about what SCAD was and how to manage it; feelings of shock, sadness, vulnerability, frustration, unfairness, guilt, embarrassment, isolation and loneliness; loss of self-confidence and reduced sense of self; fear about the future including concerns about recurrence and death; concern, confusion, frustration and helplessness in efforts to manage SCAD; negative impacts on roles and relationships, including work restrictions and family stress; and feeling dismissed by health professionals and abandoned by the health system [18]. The findings of the qualitative study demonstrated that the emotions experienced by SCAD survivors are complex, inter-related, and overwhelming [18]. The findings also demonstrated that SCAD impacted on survivors’ work life, financial status, and engagement in sport and exercise [18]. Following this qualitative work, a quantitative study was required to assess the extent of these psychosocial and lifestyle impacts, to identify those most at risk of experiencing them, and to consider their impacts on SCAD survivors’ emotional wellbeing.
Aims of the present study
The present study extends our earlier qualitative work by seeking to assess the extent and predictors of the psychosocial and lifestyle impacts of SCAD through an online survey of SCAD survivors. The aims of the study were threefold: First, to quantify each of the psychosocial and lifestyle impacts of SCAD identified in our qualitative study, thereby assessing their prevalence and relative importance. Second, to identify the characteristics of SCAD survivors who are most likely to experience these impacts. And third, to investigate the association between the SCAD impacts and survivors’ current anxiety and depression.
Method
Governance
The study was approved by the Human Research Ethics Committee (HREC) of St Vincent’s Hospital Sydney (HREC/16/SVH/338).
Participants and recruitment
Participants were recruited by the Victor Chang Cardiac Research Institute from a database of SCAD survivors participating in a larger genetic study (the VC Genetics Study) [19]. The VC Genetics Study currently involves 433 participants aged over 18 who have had at least one SCAD event, with no exclusion based on time since SCAD. All participants have adequate English language proficiency to read and understand the consent form and study information. No additional exclusions were imposed for the current study. This was the same database from which participants were recruited for our earlier qualitative study [18].
To recruit participants for the online survey, two separate sub-databases were created by the VC Genetics Study Coordinator (SH), one comprising participants whose most recent SCAD had been confirmed on angiogram by the VC cardiologist, and one comprising participants whose most recent SCAD had not been confirmed on angiogram by the VC cardiologist, either because of delays in accessing the angiogram (due to recency of the event) or inability to acquire the angiogram. During recruitment, the two databases were kept separate to facilitate separate data cleansing of responses. The ‘confirmed’ database comprised 347 SCAD survivors, while the ‘not yet confirmed’ database comprised 86 SCAD survivors, a combined total of 433.
Procedure
The recruitment period began on 10 February 2023 and ended on 6 May 2023. Each of the 433 potential participants was emailed a unique link to access the Participant Information and Consent Form (PICF). After providing written consent by ticking the ‘consent’ box to indicate that they had read and understood the PICF, participants accessed the online questionnaire available via the Research Electronic Data Capture (REDCap) platform. The questionnaire took approximately 25 minutes to complete. No identifying information was collected as no participant follow-up was involved. All respondent data were collected by self-report.
Measures
Confirmation of SCAD.
Respondents in both the ‘confirmed’ and ‘not yet confirmed’ samples were asked two self-report items to assist in confirming that they had had SCAD: 1) have you been told by a health professional that you have had SCAD, and 2) has your SCAD been confirmed by angiogram.
Sociodemographic and medical questions.
Sociodemographic information included sex, age in years, partner status, employment status, education, private health insurance, financial strain (5-point scale from none to severe), living arrangements, presence of a close confidante, and loss of a close relative or friend in the past 12 months (defined as ‘recent bereavement’). Age in years was categorised as ≤50 vs. 51–60 vs. >60. Medical information included number of SCADs, time since most recent SCAD, SCAD-specific risk factors (fibromuscular dysplasia [FMD], migraine headache, connective tissue disorder, inflammatory disorders [1, 4, 8, 9, 20]), traditional cardiac risk factors (high blood pressure, high cholesterol, diabetes, gestational diabetes, obesity, sleep apnoea, cigarette smoking), comorbidities (musculoskeletal conditions, stroke, cancer), and SCAD treatments (medications and procedures). Participants self-reported on whether they had a history of a mental health condition prior to their SCAD, namely history of anxiety, depression, and/or post-traumatic stress disorder (PTSD). Responses were combined to provide a single item relating to mental health history. Participants reported on whether they had attended a cardiac rehabilitation (CR) program or other support programs.
SCAD impact measures.
SCAD psychosocial impacts. Based on the findings of our earlier qualitative study, a set of 48 items was generated to assess the psychosocial impacts of SCAD. Respondents were asked to indicate how much they had experienced each impact during the first 6 months after SCAD. Each item was rated on a 4-point scale where 0 = not at all, 1 = a small amount, 2 = a moderate amount, and 3 = a large amount. SCAD lifestyle impacts. Also based on qualitative findings, five items asked about lifestyle impacts due to SCAD, including stopping work, reducing work hours, changing jobs, seeking financial support, and ceasing doing favorite sport or exercise. Respondents were asked to indicate whether SCAD had resulted in each impact. Each item was rated as 0 = no or 1 = yes.
Measures of current anxiety and depression.
Validated instruments were included to assess respondents’ current anxiety and depression in the two weeks prior to study participation. Anxiety. Anxiety was assessed using the Generalised Anxiety Disorder 7-item scale (GAD7) [21]. GAD7 scores ≥10 were used to indicate the presence of current anxiety. The GAD7 has good reliability and validity for detecting generalized anxiety [21], and has been well validated in the general population [22] and with cardiac patients [23]. Depression. Depression was assessed using the 9-item Patient Health Questionnaire (PHQ9) [24]. PHQ9 scores ≥10 were used to indicate the presence of current depression. The PHQ9 has been validated with cardiac patients [25] and has been endorsed by the National Heart Foundation of Australia as the recommended tool for depression screening in cardiac populations [26].
Data cleansing
Unidentified data from RedCap were saved to the statistical program (SPSSx) for data analysis. Data cleansing was undertaken to remove individuals from the ‘not yet confirmed’ sample who did not clearly have confirmed SCAD, that is, those who did not indicate on self-report that they had been told they had SCAD (n = 0 cases) or that their SCAD had been confirmed by an angiogram (n = 7 cases). Data cleansing was also undertaken to remove repeat entries from the same individual; repeat entries were identified as cases with exact entries for postcode, sex, age, living arrangements, marital status, work status, time since SCAD, and number of SCADs. In each case, the most complete entry was retained or, in cases where more than one entry was complete, the first entry was retained. In total, 31 repeat cases were deleted. The final sample comprised 310 eligible participants, 250 (81%) from the ‘confirmed’ sample and 60 (19%) from the ‘not yet confirmed’ sample. All retained cases indicated that they had been told by a health professional that they had SCAD and that their SCAD had been confirmed on an angiogram. There were no differences between the remaining ‘confirmed’ and ‘not yet confirmed’ sub-samples on any of the sociodemographic or clinical variables, or on the validated psychosocial instruments, thus the two sub-samples were combined for the analyses.
Data analysis
Prevalence of SCAD impacts.
Frequencies were calculated to identify participant endorsement of each SCAD psychosocial and lifestyle impact item. The 48 psychosocial impact items were grouped a priori into eight domains to assess: 1) emotional impacts (9 items); 2) concerns about the future (5 items); 3) difficulties managing SCAD (7 items); 4) uncertainty and confusion (5 items); 5) impacts on relationships (6 items); 6) impacts on self-perception (4 items); 7) impacts on roles (7 items); and 8) impacts of the health system (5 items). An average scale score was calculated for each domain by dividing ratings across domain items by the number of items per domain.
Predictors of SCAD impacts.
Bivariate analyses (t-tests and analysis of variance for psychosocial domains and chi-square tests for lifestyle ratings) were used to identify associations with each of the sociodemographic, medical and psychosocial participant characteristics shown in Table 1. All variables showing statistical (p ≤ 0.2) or conceptual importance were retained for the multivariate analyses, except in cases where there was collinearity with another variable. At this first step, the conservative p value of ≤ 0.2 was used to minimize the possibility of Type 2 error. Multivariate linear regression was used to identify significant predictors of psychosocial domain scores, whereas multivariate logistic regression was used to identify significant predictors of lifestyle ratings. McKelvey and Zavoina’s pseudo R-squared to estimate explained variance of the logistic regression models [27] was used since it performs closest to the ordinary least squares R-squared in simulation studies [28]. At this second step, the Benjamini-Hochberg Adjusted p value was calculated and applied to account for multiple comparisons, thereby minimizing the possibility of Type 1 error.
Association between SCAD impacts and current anxiety and depression.
T-tests and chi-square tests were used to compare psychosocial impact domain scores and lifestyle impact ratings for anxious vs. not anxious, and depressed vs. not depressed respondents. Again the Benjamini-Hochberg Adjusted p value was calculated and applied to account for multiple comparisons, thereby minimizing the possibility of Type 1 error.
Anticipated sample size and study power
From the study population of 433 SCAD survivors, it was anticipated that approximately 300 would participate. This sample size is larger than previous studies of anxiety and depression in SCAD survivors [12–14] and was deemed adequate for the required analyses.
Results
Participant characteristics
Sociodemographic and medical characteristics.
A total of 310 participants was included, representing a 72% response rate from the population of 433 SCAD survivors invited to participate. Participants’ ages ranged from 30–77 (mean = 55.61, SD = 9.07). Most were born in Australia, with others born in the UK (n = 21, 7%), New Zealand (n = 17, 6%), South Africa (n = 4, 1%), Malaysia (n = 3, 1%) and Ireland (n = 3, 1%). Two identified as being Aboriginal or Torres Strait Islander (Indigenous Australian). In terms of psychological characteristics, 21% were classified as anxious (GAD7≥10) and 21% were classified as depressed (PHQ9≥10). Other sociodemographic and clinical characteristics are shown in Table 1.
Impacts of SCAD
Psychosocial impacts.
Ratings for all SCAD psychosocial impact items across the eight domains are shown in Fig 1. In interpreting the figures, responses of ‘a large amount’ or ‘a moderate amount’ are combined to differentiate the most highly endorsed items.
The most highly endorsed item was ‘shock about having a heart attack’, from the Emotional Impacts domain (Fig 1), which was experienced by almost all respondents (86.5% a large or moderate amount). Only 2% of respondents did not experience shock. Other commonly endorsed Emotional Impacts were ‘sadness about having had SCAD’ (63.5% a large or moderate amount), and ‘feeling vulnerable’ (53.9%).
In the Future Concerns domain (Fig 1), ‘worry about having another SCAD’ was experienced by almost all respondents (80.5% a large or moderate amount), with only 2.4% not experiencing this worry. Over two thirds experienced ‘fear about the future’ (69.7% a large or moderate amount), and the remaining three items were largely or moderately endorsed by more than half the respondents: ‘uncertainty about life ahead’ (56.6%), ‘fear of dying’ (54.6%) and ‘concerns about whether life will return to normal’ (50.5%).
In the Difficulties with Management domain (Fig 1), ‘concern about triggering another SCAD’ was experienced by over three quarters of respondents (76.8% a large or moderate amount). Only 4.4% did not experience this concern. Other commonly experienced concerns were ‘being overly aware of bodily sensations’ (73.0% a large or moderate amount), ‘concerns about side effects of medications’ (62.4%); ‘frustration about fatigue and tiredness’ (59.3%) and ‘lack of control in effectively managing the condition’ (53.9%)
In the Uncertainty and Confusion domain (Fig 1), around three quarters of respondents largely or moderately endorsed ‘uncertainty about exercise and physical activity’ (73.1%) and ‘confusion about safe levels of activity and exertion’ (73.0%). A further two thirds indicated experiencing ‘uncertainty about managing your health condition’ (64.9% a large or moderate amount).
In the Impacts on Relationships domain (Fig 1), around two thirds of respondents experienced ‘worry about impacts of your SCAD on family members’ (69.9% a large or moderate amount). In the Self-perception domain (Fig 1), around two thirds experienced ‘loss of self-confidence’ (63.8% a large or moderate amount) and ‘feeling let down by your body’ (62.1%), and around half experienced concern about weight gain’ (54.3%). In the Impacts on Roles domain (Fig 1), the most common experiences were ‘loss of your previous lifestyle’ (63.2%) and ‘loss of control of your life’ (59.0%). In the Impacts of Health System domain (Fig 1), the most commonly endorsed item was ‘feeling that health professionals don’t understand SCAD’ (55.3%).
Lifestyle impacts.
Responses regarding impacts of SCAD on lifestyle are shown in Fig 2.
N = 293.
As shown in Fig 2, almost half the respondents had ceased doing a favorite sport or exercise. In terms of impacts of SCAD on work, over a third had reduced their work hours, almost a third had changed jobs, and approximately one-fifth had stopped work altogether. Combined, 176 participants (60.1%) reported at least one of these work impacts. Around one in ten had sought financial assistance.
Predictors of SCAD Impacts
Psychosocial impacts.
The variables retained on statistical grounds for inclusion in the linear regression to predict psychosocial impacts were age, education, financial strain, recent bereavement, presence of close confidante, health insurance status, and smoking status. The variables retained on conceptual grounds were mental health history, number of SCADs (dichotomized as one vs. two or more), time since SCAD, and CR attendance. The variables that did not qualify for inclusion in the multivariate analyses were sex, country of birth, partner status, employment status, living alone, and each of the SCAD treatments, comorbidities, and CVD risk factors. Results of the multivariable linear regression are shown in Table 2.
As shown in Table 2, financial strain was a significant independent predictor of higher scores on all domains, while being aged under 50 and having a trade-level education were significant independent predictors of higher scores on all but the Health system domain.
Lifestyle impacts.
The variables retained on statistical grounds for inclusion in the logistic regression to predict lifestyle impacts were age, sex, education, financial strain, living alone, presence of a close confidante, diabetes, obesity, number of SCADs, and time since SCAD. The variables retained on conceptual grounds were mental health history, number of SCADs, time since SCAD, and CR attendance. The variables that did not qualify for inclusion in the multivariate analyses were country of birth, marital status, employment status, recent bereavement, health insurance, smoking status, the remaining CVD risk factors (apart from diabetes and obesity), and each of the SCAD treatments and comorbidities. Results of the multivariable logistic regression are shown in Table 3.
As shown in Table 3, regarding work, the significant independent predictors of: ‘stopping work’ were being aged over 60, and having had more than one SCAD; of ‘reducing work hours’ were having a trade-level or university education, and having more than one SCAD; and of ‘changing jobs’ was being aged 51–60. The significant independent predictor of ‘seeking financial support’ was having financial strain, and of ceasing a favorite sport or exercise was having had more than one SCAD.
Association between SCAD Impacts and current anxiety and depression
Psychosocial impacts.
Associations between the Psychosocial Impact domain scores and current anxiety and depression status are shown in Table 4.
As shown in Table 4, ratings were highest for the domains of Emotional Impacts, Difficulties Managing SCAD, and Impacts on Roles, and were lowest for the domains of Impacts on Self-Perception and Impacts of the Health System. Scores on all domains were significantly associated with current anxiety and depression status, with respondents classified as either anxious or depressed scoring significantly higher on all Psychosocial Impact domains than those classified as non-anxious and non-depressed respectively.
Lifestyle impacts.
Associations between the lifestyle impacts and current anxiety and depression status are shown in Table 5.
As shown in Table 5, having ceased doing a favorite sport or exercise was significantly more likely in those who were currently anxious and/or depressed, compared to those who were not. Seeking financial support was significantly more common in those who were currently depressed.
Discussion
Building on our earlier qualitative study, which identified a broad range of psychosocial impacts of SCAD [18], the present study quantifies these impacts in a sample of around 300 SCAD survivors. Of all the psychosocial impacts assessed, shock about having a heart attack was the most common experience, reported by almost all participants. This is not surprising as SCAD is unexpected and occurs without warning in apparently ‘healthy’ and relatively young individuals with few CVD risk factors who are not seen as typical heart attack candidates [6, 7]. While emotional shock may subside after an initial adjustment period, it can lead to post-traumatic stress and other serious psychological outcomes [14, 29]. Indeed, the traumatic components that can trigger PTSD include the abruptness of the cardiac event, the risk of death, and a sense of loss of control during and after the event [29], all of which are highly relevant for SCAD survivors, as evidenced here.
Worries and concerns about having or indeed triggering another SCAD were the next most common experiences. Given the high recurrence rate [1, 30, 31], fear of re-events is a valid and rational concern for SCAD survivors. Indeed, this fear appears to be more common after SCAD than after other cardiac events: in an earlier study of 194 non-SCAD cardiac patients, in which we used similar data collection procedures, 48% reported fear of having another event [32], lower than the 80% in the present study. As we have noted previously, SCAD survivors need to be given opportunities to express these fears and have them acknowledged and validated [18].
Inextricably linked to fears of triggering SCAD recurrence, uncertainty and confusion about safe and recommended levels of exercise and physical activity were also common. Again the rate was higher than after non-SCAD cardiac events [32]. Previous studies have demonstrated that SCAD survivors commonly receive inadequate or insufficient information regarding safe exercise levels [11, 18, 33, 34], explaining the confusion and uncertainty around this issue. Recent evidence shows that SCAD survivors want tailored physical activity advice to suit individual needs, capabilities and preferences [33]. The need for SCAD-specific CR programs and increased SCAD awareness in general CR programs has also been strongly recommended [16, 18, 33], as has the need for guidelines on resuming physical activity after SCAD [16].
For many participants, concerns about physical activity translated into hypervigilance and avoidance behaviours. Three in four participants reported being overly aware of bodily sensations, and almost one in two had ceased doing a favorite sport or exercise. It is likely that the high level of sadness about having SCAD and feelings of loss of one’s previous lifestyle were, at least in part, a result of these lifestyle restrictions. Hypervigilance to heart-related symptoms and avoidance of triggering activities are common components of both heart-focused anxiety [35, 36] and PTSD [37], and result in reduced exercise capacity and diminished quality of life [35].
Other uncertainties were also common, including uncertainty about life ahead and about managing SCAD. Uncertainty has been a major theme in qualitative studies with SCAD survivors [18, 38]. Indeed, the challenge of navigating uncertainty has been identified as a major determinant of quality-of-life in illness generally [39] and in cardiac illnesses specifically [40, 41]. Uncertainty is heightened in illnesses with unclear management guidelines and progression trajectories [39], hence its particular relevance following SCAD.
Future-related fears were also common. With more than half the participants reporting it, fear of dying appears to be more prevalent after SCAD than after other cardiac events, where it is reported by 33% [32]. With SCAD survivors typically being younger women with family and caregiving responsibilities, the possibility of death may be particularly concerning. Future-related fears in cardiac patients, and the specific fear of death, are associated with medication non-adherence, reduced physical activity and reduced adherence to other cardioprotective behaviours [42], as well as increased likelihood of developing post-event anxiety, depression and PTSD, hence their relevance to cardiac prognosis [42, 43].
A range of other experiences are also notable. Impacts on self-perception including reduced self-confidence and concerns about weight gain were common, as were feelings of loss of control, frustration about fatigue, and concerns about side effects of medications. Over half the participants were also left worrying about the impacts of their SCAD on family members. For almost one in three participants SCAD had impacted on their working life, while one in 10 had sought financial support. These concerns and impacts all contribute to SCAD patients’ sense of loss of autonomy, which involves having reduced control over one’s behaviours and reduced choices in life [44]. Importantly, loss of autonomy reduces effective self-management and compromises emotional wellbeing [44], underscoring the importance of these concerns and losses.
Items on the Impact of health system domain were the least commonly endorsed. While over half the participants reported concern that health professionals did not understand SCAD, endorsement of other related items was relatively low. This contrasts somewhat with findings from our qualitative study, which highlighted lack of information provision and support from health professionals as a strong theme [18], and underscores the importance of using mixed research methods involving both qualitative and quantitative approaches. With continuing health professional education, it is possible that SCAD survivors will be better supported in their health-system encounters in the future. Indeed, the 2023 ESC guidelines for the management of acute coronary syndromes highlight considerable progress in the identification of SCAD and increasing consensus regarding its optimal management [5].
The present study also identified the survivor characteristics associated with an increased likelihood of experiencing high impacts after SCAD. Across almost all psychosocial domains, survivors aged under 50 experienced greater psychosocial impact than did their older counterparts, a pattern that is also seen following non-SCAD AMI [45–49]. Those experiencing financial strain were also at increased risk of psychosocial impacts, again mirroring findings seen in studies of non-SCAD AMI patients [32, 45, 46]. A recent study also identified financial strain as a predictor of recurrent cardiac events in women [50], further highlighting its negative prognostic importance. Having a trade-level education was predictive of both psychosocial and work-related impacts, again consistent with non-SCAD cardiac studies [49, 51–55].
Recurrent SCAD appears to increase the risk of some specific impacts. Having more than one SCAD was predictive of increased work impacts, including stopping work and/or reducing work hours, and increased likelihood of ceasing a favorite sport or exercise. Given that engagement in work and maintenance of exercise both contribute to physical and mental health and wellbeing during midlife [56, 57], these additional risks for people who have experienced SCAD recurrence are notable. These findings point to the additional loss of autonomy, control and choice associated with SCAD recurrence, highlighting SCAD recurrence as a particularly stressful experience [44].
The present study has also provided some evidence that experiencing these psychosocial and lifestyle impacts of SCAD increases the risk of later anxiety and depression. Higher scores on each of the eight psychosocial impact domains was associated with increased likelihood of being anxious or depressed at the time of study participation, which varied from less than one to over six years post-SCAD. Having ceased a favorite sport or exercise was similarly associated with later anxiety and depression, while seeking financial support was associated with later depression. While these associations are not necessarily causal, they point to the possibility that early psychosocial impacts of SCAD, and lifestyle restrictions, may lead to anxiety and depression. Post-cardiac event anxiety and depression are associated with reduced quality-of-life and increased risk of recurrent events and premature mortality [58–60], underscoring their prognostic importance.
Limitations
The present study has some limitations. First, the study sample appears to be relatively well-educated, most likely a result of being drawn from the larger VC Genetics Study sample, therefore it may not be representative of all SCAD survivors. Importantly though, the response rate is very high, decreasing the likelihood of participation bias in this psychosocial sub-study. Indeed, the study sample of approximately 300 is larger than most previous studies in this area. Second, based entirely on self-reporting, there is no objective verification of participants’ current anxiety and depression status, a limitation that is typical of studies of this type. Online self-report might also introduce bias due to non-completion by people with limited vision, dyslexia and other conditions. Third, participants were required to report retrospectively on the psychosocial and lifestyle impacts that had occurred in the six months after their most recent SCAD. For some, this was over 6 years prior to study participation, which may compromise the reliability of responses. It is possible that those with current anxiety or depression may respond more negatively when reflecting on past experiences, thereby artificially increasing associations between mood and SCAD-related experiences. Fourth, we did not collect data on contraceptive use, history of pregnancy, childbirth, pregnancy-related illnesses, or menopause status, therefore we were unable to account for the possible impacts of these potentially confounding factors on psychosocial and lifestyle impacts or anxiety and depression status. Similarly we did not include a measure of job responsibility level, which might have helped to provide a more nuanced understanding of the impacts of SCAD on job changes. Future studies could seek to investigate the impacts of these factors. Finally, we did not include a comparison sample of either non-SCAD AMI patients or age/sex matched healthy individuals, therefore we are unable to fully attribute the experiences reported here as being attributed SCAD exclusively. Future studies could seek to compare the relative rates of specific fears and concerns in SCAD vs. non-SCAD AMI patients, and in age/sex matched non-medical individuals. This would provide a more reliable assessment of the attribution of these concerns to the SCAD event.
Conclusion and implications
The current study contributes to our understanding of the emotional and lifestyle impacts of SCAD. The findings suggest that SCAD survivors have unmet needs in relation to accessing both informational and emotional support, and point to the need for support strategies in specific areas. First, SCAD survivors may benefit from tailored psychosocial support in the form of evidence-based psychological programs, to assist them in adjusting to and accepting their condition, with particular attention to managing fears and uncertainties regarding SCAD recurrence and the future more generally. Group programs may be particularly beneficial to enhance a sense of camaraderie, safety, empowerment and hope [34, 61]. Support in adjusting to the shock of SCAD may help to ameliorate the risks of PTSD [29]. Second, SCAD survivors need clear and reliable information about how to best self-manage their condition, with a particular emphasis on both generalized guidelines and individually-tailored advice regarding return to physical activity, exercise and sport, and other physically-demanding activities, as previously recommended [16, 18, 33, 34]. Third, survivors may need support to continue working after SCAD if they choose, including flexibility regarding reduced hours and modified tasks. In the face of the unpredictability of SCAD, maintenance of personal autonomy appears to be a particularly important aspect of recovery for SCAD survivors. Targeting of support to those who are younger, with lower education and greater financial stress, and to those who have experienced a second or subsequent SCAD appears to be warranted.
References
- 1. Hayes SN, Kim ESH, Saw J, et al. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation 2018; 137: e523–e557. pmid:29472380
- 2. Saw J, Humphries K, Aymong E, et al. Spontaneous Coronary Artery Dissection: Clinical Outcomes and Risk of Recurrence. Journal of the American College of Cardiology 2017; 70: 1148–1158. pmid:28838364
- 3. Hayes SN, Tweet MS, Adlam D, et al. Spontaneous Coronary Artery Dissection: JACC State-of-the-Art Review. Journal of the American College of Cardiology 2020; 76: 961–984. pmid:32819471
- 4. Gilhofer TS and Saw J. Spontaneous coronary artery dissection: a review of complications and management strategies. Expert Rev Cardiovasc Ther 2019; 17: 275–291. pmid:30957570
- 5. Byrne RA, Rossello X, Coughlan JJ, et al. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J Acute Cardiovasc Care 2023;
- 6. Smaardijk VR, Mommersteeg PMC, Kop WJ, et al. Psychological and clinical characteristics of patients with spontaneous coronary artery dissection: A case-control study. International Journal of Cardiology 2021; 323: 1–6. pmid:32798624
- 7. Lindor RA, Tweet MS, Goyal KA, et al. Emergency Department Presentation of Patients with Spontaneous Coronary Artery Dissection. J Emerg Med 2017; 52: 286–291. pmid:27727035
- 8. Graham RM, McGrath-Cadell L, Muller DWM, et al. The Mystery and Enigma of Spontaneous Coronary Artery Dissection. Heart, Lung and Circulation 2018; 27: 401–405. pmid:29501270
- 9. McGrath-Cadell L, McKenzie P, Emmanuel S, et al. Outcomes of patients with spontaneous coronary artery dissection. Open Heart 2016; 3: e000491. pmid:27621835
- 10. Yip A and Saw J. Spontaneous coronary artery dissection—A review. J Cardiovascular Diagnosis Therapy 2015; 5: 37–48. pmid:25774346
- 11. Wagers TP, Stevens CJ, Ross KV, et al. Spontaneous Coronary Artery Dissection (SCAD): Female survivors’ experiences of stress and support. J Cardiopulm Rehabil Prev 2018; 38: 374–379. pmid:29939880
- 12. Liang JJ, Tweet MS, Hayes SE, et al. Prevalence and predictors of depression and anxiety among survivors of myocardial infarction due to spontaneous coronary artery dissection. J Cardiopulm Rehabil Prev 2014; 34: 138–142. pmid:24280906
- 13. Saw JWL, Starovoytov A, Birnie T, et al. Comparison of psychosocial questionnaires between spontaneous coronary artery dissection (SCAD) and non-SCAD populations undergoing cardiac rehabilitation program after myocardial infarction. JACC 2016; 67: 1936.
- 14. Edwards KS, Vaca KC, Naderi S, et al. Patient-Reported Psychological Distress After Spontaneous Coronary Artery Dissection: Evidence for post-traumatic stress. J Cardiopulm Rehabil Prev 2019; 39: E20–e23. pmid:31343583
- 15. Smaardijk VR, Mommersteeg PMC, Kop WJ, et al. Psychological and clinical characteristics of female patients with spontaneous coronary artery dissection. Netherlands Heart Journal 2020; 28: 485–491. pmid:32500434
- 16. Neubeck L, McHale S, Ross M, et al. Spontaneous coronary artery dissection: a systematic review of physical and psychosocial recovery following discharge from hospital. European Journal of Cardiovascular Nursing 2022; 21: 665–676. pmid:35290455
- 17. Murphy BM, Rogerson MC, Hesselson S, et al. Prevalence of Anxiety, Depression, and Distress in SCAD and Non-SCAD AMI Patients: A Comparative Study. J Cardiopulm Rehabil Prev 2023; 43: 338–345. pmid:36892564
- 18. Murphy B, Rogerson M, Hesselson S, et al. Psychosocial impacts of Spontaneous Coronary Artery Dissection: A qualitative study. PloS One 2022; 17: e0273978. pmid:36067201
- 19. Tarr I, Hesselson S, Iismaa SE, et al. Exploring the Genetic Architecture of Spontaneous Coronary Artery Dissection Using Whole-Genome Sequencing. Circulation: Genomic and Precision Medicine 2022; 15: e003527. pmid:35583931
- 20. Maas A, Bouatia-Naji N, Persu A, et al. Spontaneous coronary artery dissections and fibromuscular dysplasia: Current insights on pathophysiology, sex and gender. International journal of cardiology 2019; 286: 220–225. pmid:30448113
- 21. Spitzer RL, Kroenke K, Williams JB, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166: 1092–1097. pmid:16717171
- 22. Löwe B, Decker O, Müller S, et al. Validation and standardization of the GAD-7 in the general population. Med Care 2008; 46: 266–274.
- 23. Conway A, Sheridan J, Maddicks-Law J, et al. Accuracy of anxiety and depression screening tools in heart transplant recipients. Appl Nurs Res 2016; 32: 177–181. pmid:27969024
- 24. Kroenke K, Spitzer RL and Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606–613. pmid:11556941
- 25. Stafford L, Berk M and Jackson HJ. Validity of the Hospital Anxiety and Depression Scale and patient health questionnaire-9 to screen for depression in patients with coronary artery disease. Gen Hosp Psychiatry 2007; 29: 417–424. pmid:17888808
- 26. Colquhoun DM, Bunker SJ, Clark DM, et al. Screening, referral and treatment for depression in patients with coronary heart disease: A consensus statement from the National Heart Foundation of Australia. Medical Journal of Australia 2013; 198: 483–484.
- 27. McKelvey R and Zavoina W. A Statistical Model for the Analysis of Ordinal Level Dependent Variables. Journal of Mathematical Sociology 1975; 4: 103–120.
- 28. Langer W and Luther M. The Assessment of Fit in the Class of Logistic Regression Models: A Pathway out of the Jungle of Pseudo-R2s with an Extension to Multinomial Logit Models. 2016: German Stata Users’ Group.
- 29. Vilchinsky N, Ginzburg K, Fait K, et al. Cardiac-disease-induced PTSD (CDI-PTSD): A systematic review. Clinical Psychology Review 2017; 55: 92–106. pmid:28575815
- 30. Gad MM, Mahmoud AN, Saad AM, et al. Incidence, Clinical Presentation, and Causes of 30-Day Readmission Following Hospitalization With Spontaneous Coronary Artery Dissection. JACC Cardiovasc Interv 2020; 13: 921–932. pmid:32327089
- 31. Virk HUH, Tripathi B, Kumar V, et al. Causes, Trends, and Predictors of 90-Day Readmissions After Spontaneous Coronary Artery Dissection (from A Nationwide Readmission Database). Am J Cardiol 2019; 124: 1333–1339. pmid:31551116
- 32. Jackson AC, Rogerson MC, Amerena J, et al. Unraveling the Complexity of Cardiac Distress: A Study of Prevalence and Severity. Front Psychiatry 2022; 13: 808904. pmid:35432039
- 33. Binnie K, Neubeck L, McHale S, et al. What do spontaneous coronary artery dissection survivors want to support their recovery? A qualitative study. Eur J Cardiovasc Nurs 2023 pmid:36656922.
- 34. Turner EA, Ivynian SE, Hickman L, et al. The Patient Experience After Spontaneous Coronary Artery Dissection. Heart, Lung and Circulation 2023. pmid:38030470
- 35. Schmitz C, Wedegärtner SM, Langheim E, et al. Heart-Focused Anxiety Affects Behavioral Cardiac Risk Factors and Quality of Life: A Follow-Up Study Using a Psycho-Cardiological Rehabilitation Concept. Front Psychiatry 2022; 13: 836750. pmid:35615455
- 36. Eifert GH, Thompson RN, Zvolensky MJ, et al. The cardiac anxiety questionnaire: development and preliminary validity. Behav Res Ther 2000; 38: 1039–1053. pmid:11004742
- 37. Fait K, Vilchinsky N, Dekel R, et al. Cardiac-disease-induced PTSD and Fear of illness progression: Capturing the unique nature of disease-related PTSD. General Hospital Psychiatry 2018; 53: 131–138. pmid:29779574
- 38. Bouchard K, Coutinho T, Reed J, et al. Recovering from spontaneous coronary artery dissection: Patient-reported challenges and rehabilitative intervention needs. Health Psychol 2021; 40: 472–479. pmid:34435799
- 39. Mishel MH. Reconceptualization of the uncertainty in illness theory. Image J Nurs Sch 1990; 22: 256–262. pmid:2292449
- 40. Clarke ST, Murphy BM, Hester R, et al. How does illness uncertainty impact recovery among patients with cardiac conditions? British Journal of Cardiac Nursing 2022; 17: 1–8.
- 41. An Y, Zhang Y, Wang L, et al. The Relationship Between Uncertainty in Illness and Quality of Life in Patients With Heart Failure: Multiple Mediating Effects of Perceived Stress and Coping Strategies. Journal of Cardiovascular Nursing 2022; 37. pmid:33764941
- 42. Birk JL, Cumella R, Lopez-Veneros D, et al. Intervening on fear after acute cardiac events: Rationale and design of the INFORM randomized clinical trial. Health Psychol 2020; 39: 736–744. pmid:32833475
- 43. Whitehead DL, Strike P, Perkins-Porras L, et al. Frequency of distress and fear of dying during acute coronary syndromes and consequences for adaptation. Am J Cardiol 2005; 96: 1512–1516. pmid:16310432
- 44. Eassey D, Reddel HK, Ryan K, et al. ‘It is like learning how to live all over again’ A systematic review of people’s experiences of living with a chronic illness from a self-determination theory perspective. Health Psychology and Behavioral Medicine 2020; 8: 270–291. pmid:34040872
- 45. Murphy B, Le Grande M, Alvarenga M, et al. Anxiety and Depression After a Cardiac Event: Prevalence and Predictors. Frontiers in Psychology 2020; 10: pmid:32063868
- 46. Murphy BM, Elliott PC, Ludeman D, et al. ’Red flags’ for anxiety and depression after an acute cardiac event: 6-month longitudinal study in regional and rural Victoria. European Journal of Preventive Cardiology 2014; 21: 1079–1089.
- 47. O’Neill CD, Vidal-Almela S, Terada T, et al. Sex and Age Differences in Anxiety and Depression Levels Before and After Aerobic Interval Training in Cardiac Rehabilitation. J Cardiopulm Rehabil Prev 2022; 42: 15–21. pmid:34793363
- 48. Bruyninx G, Grenier J, Greenman PS, et al. Prevalence of Symptoms of Anxiety Disorders and Depression in Cardiac Rehabilitation Patients in an Academic Hospital: a Case Study. Psychiatric Quarterly 2021; 92: 273–287. pmid:32621076
- 49. Olsen SJ, Schirmer H, Wilsgaard T, et al. Cardiac rehabilitation and symptoms of anxiety and depression after percutaneous coronary intervention. Eur J Prev Cardiol 2018; 25: 1017–1025. pmid:29846117
- 50. Georgiades A, Janszky I, Blom M, et al. Financial strain predicts recurrent events among women with coronary artery disease. International Journal of Cardiology 2009; 135: 175–183. pmid:18619689
- 51. Allabadi H, Alkaiyat A, Alkhayyat A, et al. Depression and anxiety symptoms in cardiac patients: a cross-sectional hospital-based study in a Palestinian population. BMC Public Health. BMC, 2019, p. 1–14.
- 52. Rawashdeh SI, Ibdah R, Kheirallah KA, et al. Prevalence Estimates, Severity, and Risk Factors of Depressive Symptoms among Coronary Artery Disease Patients after Ten Days of Percutaneous Coronary Intervention. Clin Pract Epidemiol Ment Health 2021; 17: 103–113. pmid:34733349
- 53. Sharma Dhital P, Sharma K, Poudel P, et al. Anxiety and Depression among Patients with Coronary Artery Disease Attending at a Cardiac Center, Kathmandu, Nepal. Nursing Research & Practice 2018: 1–6.
- 54. Pająk A, Jankowski P, Kotseva K, et al. Depression, anxiety, and risk factor control in patients after hospitalization for coronary heart disease: the EUROASPIRE III Study. Eur J Prev Cardiol 2013; 20: 331–340. pmid:22396247
- 55. Gu G, Zhou Y, Zhang Y, et al. Increased prevalence of anxiety and depression symptoms in patients with coronary artery disease before and after percutaneous coronary intervention treatment. BMC psychiatry 2016; 16: 259. pmid:27450548
- 56. Modini M, Joyce S, Mykletun A, et al. The mental health benefits of employment: Results of a systematic meta-review. Australas Psychiatry 2016; 24: 331–336. pmid:26773063
- 57. Rahman MM, Jagger C, Leigh L, et al. The Impact of Education and Lifestyle Factors on Disability-Free Life Expectancy From Mid-Life to Older Age: A Multi-Cohort Study. International Journal of Public Health 2022; 67. pmid:36046258
- 58. Presciutti A, Newman MM, Vranceanu A-M, et al. Associations between depression and anxiety symptoms with quality of life in cardiac arrest survivors with good neurologic recovery and informal caregivers of cardiac arrest survivors. Journal of Affective Disorders Reports 2020; 2: 100046.
- 59. Berg SK, Rasmussen TB, Thrysoee L, et al. Anxiety, depression and risk behaviour in cardiac patients. Findings from the national DenHeart survey. European Heart Journal 2017; 38: ehx502.2238.
- 60. Tully PJ, Cosh SM and Baune BT. A review of the effects of worry and generlised anxiety disorder upon cardiovascular health and coronary heart disease. Psychology, Health & Medicine 2013; 18: 627–644.
- 61. Delisle VC, Gumuchian ST, Rice DB, et al. Perceived Benefits and Factors that Influence the Ability to Establish and Maintain Patient Support Groups in Rare Diseases: A Scoping Review. Patient 2017; 10: 283–293. pmid:28004275