Living in the Shadow of a Heart Attack: Coping with the Fear of Recurrence

While it is already well-known that heart attack survivors may deal with depression and anxiety, the unique effects of psychological stress, particularly the fear of additional heart attacks, has received less attention concerning their mental and emotional recovery.

“Our goal was to understand how survivors feel about the chance of having another heart attack. We specifically looked at how demographics, health behaviors, and patients’ views on their illness affect both their fear of recurrence and their overall stress levels,” said Sarah Zvonar, Ph.D., R.N., C.C.R.N., the lead author and a post-doctoral fellow at Indiana University School of Medicine in Indianapolis.

To recruit volunteers for the study, researchers utilized Facebook advertisements targeting individuals who had experienced a heart attack within a year between 2021 and 2022. Interested participants were invited to join a dedicated Facebook group, where they could access standard questionnaires that evaluated fear of recurrence, illness perceptions, current stress levels, anxiety, and depression. Participants also shared demographic information and details about their present cardiovascular health practices. Researchers reviewed data from 171 heart attack survivors who completed the questionnaires twice, approximately six weeks apart (about six and eight months following their heart attack).

The study revealed the following key findings:

• The fear of experiencing another heart attack had a considerable effect on individuals’ perceptions of their health and levels of perceived stress.
• Despite a six-week gap between the two surveys, the average duration from the initial heart attack to the first survey was six months. Notably, the fear of recurrence was pronounced six months post-event and continued to be significant at the follow-up around eight months.
• Even when accounting for depression and anxiety, the influence of the fear of recurrence on health perceptions and perceived stress did not lessen from six months to eight months following the initial heart attack.
• Although participants generally reported low alcohol consumption, those who drank more were more likely to experience elevated fear of recurrence and stress levels. The average reported alcohol intake was 1.35 drinks per week, with a range spanning from 1 to 6 drinks weekly.
• Compliance with dietary restrictions, smoking, and exercise recommendations did not notably predict fear of recurrence or stress levels.

“Healthcare often focuses primarily on anxiety and depression, potentially overlooking a critical issue: patients may harbor a fear of having another heart attack stemming from various factors,” Zvonar noted. “Survivors face a lot of new health information to assimilate after their first heart attack, including diet modifications, exercise routines, follow-up care, and cardiac rehabilitation. Furthermore, our findings suggest that the fear of recurrence persists from six to eight months post-heart attack, highlighting the potential need for ongoing follow-up and mental health support.”

This study has some limitations. The participants were predominantly young heart attack survivors, with an average age under 40, which may not be representative of older heart attack survivors. According to the American Heart Association, the average age of a first heart attack is 66 for men and 72 for women in the U.S. Additionally, the study lacked proper representation across various racial and ethnic groups, warranting further research into the relationship between fear of recurrence and race.

Moreover, as the research occurred during the COVID-19 pandemic and relied on Facebook for recruitment, it was challenging to collect and verify many clinical details (like heart attack severity and medication usage). Consequently, other health factors that could affect psychological well-being and fear of recurrence weren’t analyzed.

“This study should be replicated in a clinical setting that collects critical medical data; however, I believe the results may remain consistent,” Zvonar added.

“Despite being preliminary and based on a small group of younger individuals who volunteered via Facebook, these findings are noteworthy,” commented Glenn N. Levine, M.D., a professor at Baylor College of Medicine and advisor on the 2021 American Heart Association scientific statement related to psychological health and the mind-body connection. “Healthcare professionals should consider not only the disease but the individual as a whole. This study indicates that it’s essential to acknowledge psychological aspects such as depression and stress after a heart attack, along with the genuine fear many may have of experiencing another cardiac event, which could adversely affect their psychological state. Poor mental health can elevate the risk of future heart conditions, and this fear might become a self-fulfilling prophecy for some.”

Details regarding the study’s background and methodology include:

• The study comprised 171 adults (average age of 39 years, 69% women), with 41% identifying as white, 33% as Black, 6.4% as Hispanic or Latino, 5.3% as American Indian or Alaskan Native, 4.1% as Asian, 2.3% as Native Hawaiian or Pacific Islander, and 2.9% preferring not to disclose their race.
• The majority of participants were recruited via Facebook, with some additional participants sourced from a level-one trauma center in the Midwest.
• Approximately 33% of participants currently used tobacco; 59% did not meet the recommended physical activity of 150 minutes weekly; about one-third reported managing their fat and sodium intake regularly; and average alcohol intake was 1.35 drinks per week. Just 26% of participants attended at least one cardiac rehabilitation session.
• The most commonly reported health conditions among participants were high blood pressure (46.2%) and Type 2 diabetes (44.4%). Meanwhile, 62% reported no family history of sudden heart attacks.
• Participants completed various psychological assessments online, including the Brief Illness Perception Questionnaire, the Fear of Progression Questionnaire, the 10-item Perceived Stress Scale, and the 21-item Depression Anxiety Stress Scales.
• The researchers evaluated the possible impact of depression, anxiety, demographic variations, and heart disease risk-related behaviors on fear of recurrence and perceived stress levels.

Co-authors, disclosure information, and funding sources are available in the original manuscript.

It is important to note that the conclusions and findings presented at the American Heart Association’s scientific meetings are solely attributed to the study authors and do not necessarily reflect the Association’s stance. The Association does not guarantee the accuracy or reliability of these findings. Abstracts at these meetings are not peer-reviewed but are curated by independent review panels based on their potential to broaden the scientific discourse presented at the event. These findings are considered preliminary until they are published in a peer-reviewed scientific journal.

The American Heart Association primarily receives funding from individual donations, although foundations and corporations (including those in the pharmaceutical and medical device sectors) also contribute. The Association has strict protocols to ensure that these contributions do not influence its scientific content. For more details regarding the Association’s financial information, including revenues from pharmaceutical, biotech firms, and health insurance companies, please refer to the provided resources.