Fear of another heart attack may be a major source of ongoing stress for survivors

While it is widely acknowledged that survivors of heart attacks may experience depression or anxiety, less attention has been given to the impact of psychological stress and how the fear of another heart attack may impact patients' mental and emotional recovery.

"We wanted to understand what survivors thought about the possibility of another heart attack. Specifically, we examined how demographics, health behaviors and the patient's perception of their illness predicted both fear of having another heart attack and perception of their current stress," said lead study author Sarah Zvonar, Ph.D., R.N., C.C.R.N., a post-doctoral fellow at the Indiana University School of Medicine in Indianapolis.

Researchers placed advertisements on Facebook recruiting volunteers for the study -- people who had experienced a heart attack during a one-year period between 2021-2022. Those who responded were directed to a newly created Facebook group with links to standard questionnaires that assessed fear of recurrence, perceptions of their illness, current stress, anxiety and depression. Participants also provided demographic details and information on their current cardiovascular-related health behaviors. The researchers analyzed data for 171 heart attack survivors who completed the questionnaires twice, about six weeks apart (approximately six and eight months after their heart attack).

The study found:

• The fear of experiencing another heart attack significantly impacted the individual's perception of illness and their level of perceived stress.
• The time between surveys was six weeks, however, the average time from the initial heart attack to the first survey was 6 months. The fear of another heart attack was significant at 6 months after the heart attack and still significant at follow-up around 8 months.
• Controlling for depression and anxiety did not reduce the impact of fear of recurrence on illness perception and perceived stress from six months to about eight months following the initial event.
• Although the average alcohol intake was low among all participants, those who consumed more alcohol seemed to be more likely to experience both fear of another heart attack and higher levels of perceived stress. Average alcohol intake was 1.35 drinks per week, with a range of 1-6 drinks per week.
• Adherence to diet, smoking and exercise guidance did not significantly predict fear of recurrence or perceived stress.

"Health care often focuses solely on anxiety and depression, and treatment may include antidepressants, missing an important issue -- patients may be experiencing fear of having another heart attack for another reason," Zvonar said. "For example, there is so much new health information for them to process after a first heart attack -- how to improve their diet, exercise, follow-up care, cardiac rehabilitation, etc. In addition, we found that the fear of recurrence did not diminish from 6-8 months after the heart attack, which indicates that people may need extended follow-up and mental health support."

The study has several limitations. Results from this group of young heart attack survivors, whose average age was younger than 40, may not be generalizable to older heart attack survivors. In the U.S., the average age at a first heart attack is 66 years for men and 72 years for women, according to the American Heart Association's Heart Disease and Stroke Statistics 2024 Update. Another limitation was that race and ethnicity did not have sufficient representation in this study. More research should be done to determine the exact relationship between fear of another heart attack and race.

In addition, since the study was conducted during the COVID-19 pandemic via Facebook, it was not possible to gather and verify many clinical details (such as the severity of heart attack and medication use). This means some additional health factors that might influence psychological well-being and fear of recurrence were not able to be analyzed.

"The study needs to be replicated in a clinic with the collection of medical data; however, I would anticipate that the results would be similar," Zvonar said.

"While preliminary and based on a small sample of younger people who self-selected themselves in response to a Facebook advertisement, the findings in this study are nevertheless noteworthy," said Glenn N. Levine, M.D., a professor of medicine at Baylor College of Medicine and chair of the 2021 American Heart Association scientific statement, Psychological Health, Well-Being, and the Mind-Heart-Body Connection. "As health care professionals, it's important to consider both the disease and the person. This study suggests that we should consider not only psychological factors, such as depression and stress after a heart attack, but additionally recognize that many people may have a genuine fear of experiencing another heart attack, which can also have a negative impact on their psychological health. Given that poor psychological health increases the risk of future heart problems, this fear may, to some extent, become a self-fulfilling prophecy in some people."

Study details, background and design:

• The study included 171 adults (average age of 39 years, 69% women). 41% of the participants self-identified as white 33% as Black; 6.4% identified as Hispanic, Latino, or of Spanish origin; 5.3% as American Indian or Alaskan Native; 4.1% as Asian; 2.3% as Native Hawaiian or Pacific Islander; and 2.9% preferred not to answer, and
• Most participants were recruited through Facebook advertising, while 17 were recruited through a level-one trauma center (highest level of care) in the Midwest.
• Approximately 33% of participants currently used tobacco; 59% did not achieve the recommended 150 minutes per week of physical activity; around one-third reported managing their fat and sodium intake on most days of the week; average alcohol intake was 1.35 drinks per week. Only 26% of the study participants had attended at least one session of cardiac rehabilitation.
• The two most reported health conditions occurring among participants included high blood pressure (46.2%) and Type 2 diabetes (44.4%). No family history of sudden heart attacks was reported by 62% of participants.
• Participants completed standard psychological questionnaires 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 analyzed the potential impact of depression, anxiety, demographic differences and behaviors related to heart disease risk on the fear of recurrence and perceived stress.

Co-authors, disclosures and funding sources are listed in the manuscript.

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