A critical of review of the management of Stress/Anxiety

The body of literature relating to the psychological factors that are associated with myocardial infarction is huge, with many differing studies, analyses and opinions of varying degrees of authority.  The whole issue of anxiety and stress specifically relating to myocardial infarction represents a major proportion of this total body. A number of articles define it, some quantify it, many more describe its clinical implications and a few make suggestion about how to deal with it. In this article we shall attempt to look critically at representative samples of the modern literature in all of these sub-divisions and try to draw some appropriate conclusions from them all.

Coronary artery disease is a great burden on the morbidity of the Nation with 150,000 patients surviving acute myocardial infarction every year in the UK. (Dalal & Evans 2003)

By way of setting the scene for this review we should perhaps visit a commentary by John Lynch (1996) who in a rather tongue-in-cheek way describes the typically stoical outlook which seems to characterise many of the older generation by denying that stress or anxiety exist. It’s opening paragraph is worth quoting verbatim:

Reading the paper by Jones and colleagues I am reminded of growing up in Australia, where my parents impressed upon me the importance of not being a "whinger." In fact, it was common for  my grandmother, when asked how she was feeling, to reply "mustn't grumble." Such stoicism even in the face of malaise was thought to be a positive personality disposition.

This is not idle musing, it is actually a very valid point which we should take on board before embarking on our review. Lynch’s observations point to a fundamental flaw in a great many trials (admittedly, they tend to be the older ones)  that rely for their input on self-reported episodes. A moment’s reflection will suggest that the neurotic personality type, who, arguably will be more likely to admit to signs and symptoms of stress and anxiety is likely to complete a self-reporting questionnaire by overstating his symptomatology. (Iribarren et al. 2000)

The grandmother of Lynch’s quote would clearly be at the other end of the spectrum and be likely to respond by saying that everything was fine when she might be actually having severe problems. In short, Lynch observes that this can be a major source of observer bias. The subject who considers himself to be living a stressful life is more likely to give greater emphasis to symptoms when prompted for evidence of cardiovascular pathology. (Everson et al. 1996)

Another problem which we may expect to encounter is that the concept of stress has changed quite considerably, arguably even over the last few decades. Soldiers in the First World War and to a lesser extent in the Second, would commonly receive a diagnosis of DAH (Disordered Action of the Heart) as a diagnosis for the signs of palpitations and the symptoms of stress. Today we may call the same situation combat fatigue or reactive stress or even post-traumatic stress. The academic psychologist may even choose to sub-define it further into areas of hostility, depression, aggression or hopelessness. This makes the comparisons of similar clinical trials quite difficult, as they may be ostensibly measuring stress, but in fact may actually be quantifying it in quite different ways (see on). (Bosma et al. 1997)

Jones (Jones & West 1996) suggests that the original concept of rehabilitation after myocardial infarction was to:

“ensure the best possible physical, psychological and social conditions so that patients ... may, by their own efforts, preserve their proper place in society" and this view has been shared by others (WHO Expert Committee 1964) (Task Force - 1992)

Not so very long ago the popular advice when it came to rehabilitation was the “Armchair treatment” (Levine & Lown 1952) where the recovering patient was told to rest and not strain the heart - often being discharged from hospital with no more than one sheet of written advice (Horgan et al. 1992))

The considerations of the importance of the psychological sequelae of myocardial infarction have only gained popular recognition in the comparatively recent past. (Lloyd & Cowley 1978) Only recently have concerted and organised efforts been made to specifically tackle the ravages of anxiety and depression (Mayou et al. 1978) (Adsett & Bruhn 1968)

The national service framework

Over the recent few years the Government has been rolling out a number of national service framework protocols which, effectively define the goals and targets for the NHS in a number of different areas, together with the suggested means of achieving those goals and targets.

The national service framework for coronary heart disease was introduced in March 2000 and starts by recognising that patient’s beliefs and behaviour, together with their emotions and attitudes have a great impact on the eventual clinical outcome. With specific relevance to this article, the national service framework calls for routine integration of “psychosocial assessment …and psychological approaches” into the cardiac rehabilitation schemes.

Bass & Mayou (2002) condense the recommendations of the national service framework thus:

“Provide education about heart attacks and secondary prevention and correct misconceptions

Agree and record goals for exercise, return to work, and everyday activities; provide copies for patients, medical notes, and primary care

Offer home exercise programme or community group exercise, or both

Routine early review of symptoms, activity, and progress with rehabilitation and secondary prevention goals

Menu of specific interventions, including stopping smoking, diet, and identification and treatment of psychological and behavioural difficulties”
The national service framework recognises that there is evidence (see on) that both anxiety and depression independently and adversely affect the outcome of the patient post-myocardial infarction, both in terms of morbidity and mortality. Those with the severest psychological disturbances appear to have the worst prognosis. It is recognised that there may well be an element of cause and effect in that statement but various studies strongly suggest that there is an independent effect from both anxiety and depression.

The paper by Dalal is reviewed in the Literature review section of this article which looks specifically at the implementation of the recommendations of the national service framework and the National Institute for Clinical Excellence
The National Service Framework quotes a number of specific goals in relation to rehabilitation. From the perspective of this article, the salient features are;
“The national service framework goal for cardiac rehabilitation states that every hospital should ensure that >85% of patients discharged from hospital with a primary diagnosis of acute myocardial infarction are offered cardiac rehabilitation and that at one year after discharge at least 50% of people should be non-smokers and have a body mass index <30 kg/m2..”
The national service framework guidelines have to be implemented in full by 2010.

The nature of stress

We all think that we know what stress is and are probably sure that we can recognise it in ourselves. A moment’s investigation however, suggests that it is both hard to define and sometimes deceptively hard to recognise (Crampton et al. 1995). It is important to define our terms. We must distinguish between the biological type of stress (Physical stress) and psychological stress. The two entities are similar but fundamentally different. The second point to consider is the psychological manifestations of stress are actually many different possible responses to any number of potential triggering factors.

The “founding father” of stress research, Hans Selve, defined stress as  "the non-specific response of the body to any demands made upon it" (1956). That definition was refined later by Crampton (et al. 1995) in her book by saying that it was “an internal state or reaction to anything we consciously or unconsciously perceive as a threat, either real or imagined”. This is very relevant to our considerations here as a myocardial infarction is considered by the lay person (not without some justification) as a major threat to life. We will see, in some of the papers reviewed, that unconscious perception can be just as potent a cause of stress as consideration of the overt.

Selve went on to state that stress can evoke many different feelings and emotions. He quotes “frustration, fear, conflict, pressure, hurt, anger, sadness, inadequacy, guilt, loneliness, or confusion.”  In further consideration of our topic, although we are primarily considering the stresses engendered in a patient by a myocardial infarction, we must not forget the other manifestations of stress in the relatives of the patient, particularly if the patient is critically ill, or even subsequently dies (Adsett & Bruhn 1968)

The other side of the argument is presented by Apter (2001), who is perhaps better known for his championing of reversal theory. He  points out that many people believe that they must avoid stress if they want to live longer, but stress has conferred an evolutionary advantage in biological terms. He suggests that stress is “the salt and spice of life”. some people need a degree of stress to perform well, some people thrive on it and that to have no experience of stress at all we would have to be dead. 

 Selve has defined (above) the basic “biological” interpretation of stress while the definition produced by  Crampton begins to incorporate the possible psychological elements that generate the biological responses.

Shattner (2003) elucidates further with the consideration of the psychological responses that various stresses produce, while (Musselman et al. 1998) takes the definition a stage further still with the introduction of the concept that stress can have both positive and negative components. Januzzi (et al. 2000) points out that stress, to a degree, is an integral and unavoidable feature of living, in much the same vein as Apter, but he defines it further with his subdivision of humans into those who find stress hard to deal with (non-copers), and those individuals who appear to be at their best in stressful situations (copers)

Literature Review

We have referred earlier to the wealth of literature on this subject and it is therefore difficult to find a place to start. The paper by Jones and West (1996) does, however, provide a good basis as it considers a number of smaller trials on the subject and carries out a meta-analysis and it therefore able to draw a number of significant conclusions from that. It is of particular value as it assesses the patients (and their spouses) at discharge, and at six and twelve months after discharge. The cohort was nearly 2,500 patients admitted over two years. From the point of view of relevance to our considerations here, the authors considered the efficacy of a number of interventions including:

Rehabilitation programmes comprising psychological therapy, counselling, relaxation training, and stress management training over seven weekly group outpatient sessions for patients and spouses.

Their findings were that at six months they could find no statistically significant difference between the control group and the rehabilitation group in self-reported anxiety (33%)  or depression (19%). A t the twelve month marker, the study still found no significant difference in these groups, nor in the groups in terms of clinical complications, sequelae or death rates.

The actual figures quoted show that at the six month period there was a slight improvement in the death rate in the rehabilitation group (34 vs. 47) but by the twelve month assessment the difference had been lost (76 vs. 75)
This may explain the reason why some shorter term trials may find a benefit when longer term trials tend not to. (Mayou et ql 1981) (Rahe et al. 1979)

In terms of the physical sequelae most expected to be influenced by anxiety and depression such as angina frequency or use of medication, only very modest ( and not statistically significant) differences were found
The authors therefore came to the conclusion that:

Rehabilitation programmes based on psychological therapy, counselling, relaxation training, and stress management seem to offer little objective benefit to patients who have experienced myocardial infarction compared with previous reports of smaller trials.
Despite these findings it is interesting to note that both the patients and their partners rated the content of the rehabilitation programmes highly which may suggest a “quality of care” role for rehabilitation, even if psychological benefit cannot be directly demonstrated.

The study itself was well constructed with a large entry cohort which should have been sufficient to demonstrate statistical trends which the smaller studies may not have been able to do.

Its major criticism, however, was that the nature of the interventions that were compared, were not directly referable for one group to the next. For example, one trial dealt with anxiety by means of giving information about the patient’s condition to allay fears, whereas another was teaching relaxation skills. Some used group discussions and others used individual counselling. Each may be commendable in their own right, but to pool the results under the heading of “anxiety reduction” and find that it has no statistical benefit does not seen particularly appropriate. Although not specifically relevant to our considerations in this article, it is worthy of note that the authors did not include other important elements of rehabilitation such as smoking, exercise, diet and weight control in the programme for analysis.

In its defence, the trial did have some positive features such as an “all encompassing” inclusion criteria. Some other trials have analysed data from predominantly the under 65 age group for example (Friedman et al. 1984)

We have reviewed this paper in some detail as its consequences for our article are quite profound. In order to produce a fully balanced argument we also note the paper by Linden (et al 1996) was a meta-analysis of psychosocial interventions after myocardial infarction and on this occasion they found that such interventions did produce clinical benefit.

In order to take this argument further we will turn to a paper by Hemmingway (& Marmot 1999) which looked at the same psychosocial factors, but also considered them in relation to the aetiology of myocardial infarction. It is a well written and self-critical paper. It is very detailed and therefore we shall not present all of the findings here. Again, it is a paper that takes an overview of other, smaller previously published papers and also performs a meta-analysis on some of them.

The previously mentioned role of psychological factors in the aetiology of myocardial infarction is outlined. The significant findings (relative to our considerations) are that the Type A personality (exhibiting frequent hostility) was found to be a significant aetiological factor in 6 out of 14 studies considered and anxiety and depression were found to be significant factors in 11 out of 11 studies considered. Not only were these factors found to be significant, but their presence had a significant prognostic role in the outcome of myocardial infarction.

The authors point to the fact that the various psychosocial factors considered may either act independently or exert an accumulative and additive effect (Williams et al. 1997) and that they may also have different relevance at different times in a patient’s life (Kuh et al. 1997). The discussion of the value of these observations is quite significant. They point to the fact that anxiety and depression (for example) may be related to other equally significant factors such as the amount of tobacco smoked has a linear relationship with the degree of both anxiety and depression (Pieper et al. 1989) it therefore follows that treating them may well have a positive bearing on the incidence of myocardial infarction in the first instance.

They also consider the fact that some papers state that both depression and coronary artery disease share a common antecedent - stress. (Marmot et al. 1997)

The next paper that we shall examine is a commentary by Pither (et al 1997). We have chosen this paper because it puts into stark perspective the findings of the Jones paper (above). Although the Jones paper did carry a degree of self criticism and analysis, according to Pither it overlooked one very important point. Pither states that the reason why their study did not find any benefit from any of the psychological interventions studied could be due to one of two reasons:

“Was the lack of effect due to failure to teach a programme that could be utilised by the treated patients, or are psychological techniques ineffective in reducing mortality?”

On reflection this is absolutely fundamental in trying to address any further progress in the field. Were the findings of the study were negative simply because the particular measurers employed to try to minimise anxiety and depression were not taught well enough or not in a way that the patients could subsequently employ? Alternatively, was the reason that they could not demonstrate any benefit simply because such psychological techniques are of no value in reducing the overall mortality post myocardial infarction?

The authors point out that the quality of the psychological intervention was not recorded. Some may have been given by specialist rehabilitation nurses, experienced and skilled in the techniques of teaching and instruction, alternatively, the courses could have been run by an inexperienced nurse who had been drafted in at a few days notice just for the purposes of the study who may have had only minimal training. (Roth & Fonagy 1996)

The authors finish with a perfectly valid criticism:

“There is a distinct risk that this study will inform the world that there is no place for psychological approaches in rehabilitation after myocardial infarction, while methodologically superior work tells us otherwise.(Lewin et al. 1992)  In fact this study tells us very little.”
Having considered a number of papers that have evaluated the efficacy of interventions aimed at anxiety and depression in the field of myocardial infarction. We will now examine a paper that looks at a number of specific interventions and evaluates each independently. The paper by Davies (et al. 2004) looks at many different modalities but actually spends most of its effort on considering the role of SSRI’s in post myocardial infarction patients. At the beginning of the paper, the authors cite plenty of previous trials which link both depression  (Frasure-Smith et al 1995) and anxiety (Davies et al.1999) to both myocardial infarction and hypertension.


The Frasure-Smith paper (1995) reported a 3.5 fold increase in the death rate patients who suffered from depression of anxiety after myocardial infarction. Depression has equally been cited as one of the causes of hypertension which is a demonstrable cause of cardiovascular complications. Equally Kawachi (et al. 1994) cite a link between anxiety and sudden death syndrome.

Although we can see, from the papers cited above, that there may be a body of opinion that feels that treatment of anxiety and depression has no demonstrable effect on the eventual morbidity and outcome of myocardial infarction, there is a greater body of opinion that feels that treatment is indicated both before and after the actual event as this may well reduce the morbidity.
The Davies paper spends a lot of time considering the drug treatment of anxiety and depression in patients who have cardiovascular disease. To condense his findings into a few words -SSRI’s are probably the drug of choice and tricyclic antidepressants are best not used at all in cases with any degree of myocardial ischaemia. The authors quote a 60-70% remission rate with symptoms of depression with SSRI’s over a six week optimum dose course. (Sauer et al. 2003)

The findings do appear to have a pharmacological basis to them. SSRI’s work by effectively increasing the serotonin levels at the level of the synapse. (Lehnert et al. 1987) this appears to have an effect in reducing symptoms of anxiety and depression (Richerson et al. 2001) but tricyclic antidepressants are thought to increase the incidence of ectopic pacemaker activity and are therefore contraindicated. (Sauer et al. 2003)
The authors point to the fact that one reason why patients suffering from anxiety and depression may get a higher complication rate post-infarct, is that anxiety and depression may both impair the patient’s ability to stick with any treatment programmes, particularly if they have any less-than-optimum issues with tolerability. This may be part of the reason why there appears to be a correlation between anxiety and depression and increased cardiovascular morbidity. (Richerson et al 2001)
The paper expends a considerable effort on the safety issues surrounding drug use which, although both interesting and commendable, is not of particular relevance to this article. With regard to efficacy however, the paper points to specific papers which show the positive effect of the SSRI’s in treating anxiety and depression in specific cases of cardiovascular disease, post infarction states and hypertension. (Glassman et al. 2002) (McFarlane et al. 2001)

In terms of hard statistics, the authors point to studies which show a reduction in cardiac events when anxiety and depression was treated by SSRI’s (22.4% vs 14.5%) (Strik et al. 2000)

The paper also considers non-pharmacological interventions at some length. Cognative behaviour treatment was shown to reduce symptomatology in chest-pain patients (Polyak 2001)

In conclusion, this is a well constructed and well written paper with important messages for all those involved in rehabilitation of the cardiovascularly compromised patient.

Thus far we have examined papers that have concentrated primarily on the theoretical aspects of post-myocardial infarction rehabilitation. We will therefore turn to the recent paper by Dalal & Evans (2003) which examines the practical aspects of achieving the national service framework standards for cardiac rehabilitation. It is of specific relevance to this article because, in addition, it considers the role of the specialist nurse in the implementation of the strategy.
The study looked at the treatment and rehabilitation of 106 post myocardial infarction patients in a Cornwall practice over a 12 month period. The nurse was specifically employed to visit post-myocardial infarction patients in hospital, prior to discharge and offered them either hospital based rehabilitation or community based rehabilitation. Approximately half of the patients chose each group. In specific relation to our article the paper concludes with the comment:

“Lessons learnt: National service framework targets for cardiac rehabilitation and secondary prevention can be achieved in patients who survive a myocardial infarction by integrating rehabilitation services (home and hospital) with secondary prevention clinics in primary care. Nurse led clinics in primary care facilitate long term structured care and optimal secondary prevention.”

The study was conceived after  a previous investigation (Cardiac rehabilitation, 1998) found that the national uptake of cardiac rehabilitation was poor despite the fact that some trials (cited above) have shown that rehabilitation has a positive impact on patient’s lives. The study worked to a protocol called “The Heart Manual” (no reference quoted) which purports to be a step-by-step guide through the various aspects of cardiac rehabilitation.

Interestingly, the authors submitted their costs for analysis. Each manual (or patient pack) cost £22 and the total cost for all of the post myocardial infarction patients in a twelve month period (106) the overall cost was £60,000

This paper is primarily describing the difficulties surrounding the setting up of a national service framework compliant rehabilitation system. It has not been going long enough to allow for any meaningful analysis of the statistics. Time will tell if the expenditure of both time and money is going to be worthwhile.
The next paper to be considered is one by Macleod (et al. 2002 (1)). It is basically a commentary about stress and cardiovascular disease in Scottish men. The reason why it especially merits examination is the fact that many of the articles that we have so far considered, have looked at the effects of stress as part of the psychosocial background of the patients. This particular study goes to great pains to detach the stress related to the social deprivation angle from the stress generated by the disease process. The actual study looked at over 5,500 men over a 21 yr. period. With particular reference to our article, it considers the incidence of self-reported stress.

The results show a positive correlation between stress and angina. High stress levels were found to be associated with higher levels of hospital admissions. The interesting result of this study is that the increase in hospital admissions was not reflected in the severity of the disease process.

After careful analysis, the authors were able to conclude that the reason for the increased hospital admissions was the fact that the higher stress groups were more likely to over-report symptoms and when they were investigated they did not show a correlation with severity of underlying heart disease. Thus, with this finding, we effectively come full circle from the paper by Jones and West (1996). The authors conclusion that:
“The data suggest that associations between psychosocial measures and disease outcomes reported from some other studies may be spurious.“

concurs with some of the findings of that first paper.  By detaching the psychosocial stress from the pure psychological forms of stress, the authors felt able to make a distinction. As stress per se. was found to show a weakly inverse relationship to all of the indices of cardiac disease, they were able to conclude that socially advantaged men tended to perceive themselves as amongst the most stressed sections of society and in this respect stress appeared to have a protective effect.
Arguably, the most important finding of this study comes towards the end. The authors conclude that the higher levels of stress appears to be associated with an adverse behaviour pattern when it comes to assessing risk factors. As we have commented in other papers, increased stress correlates highly with increased cigarette smoking. Hence the possible correlation between higher stress and higher angina levels. This is not reflected by an increase in baseline myocardial ischaemia. Overall, there was an increased hospital admission rate (for all causes) associated with increased stress rates. Hypertension and other ill defined cardiovascular abnormalities such as varicose veins were all over represented in the “high stress” group.

This paper makes a commendable self criticism (in the way that the Jones and West  paper did not). The authors felt that the reason that they got an apparent excess of “positive” findings was that, because of the self-reporting techniques used, the patients who perceived themselves as stressed were equally more likely to report symptoms that they believed were attributable to cardiovascular disease which, in turn, lead to an apparent heightened relationship between increased stress and angina. The authors sum this effect up in a very concise way that could actually be relevant to most of the papers that we have reviewed thus far:

“Spurious associations between exposures and outcomes are to be expected when both are substantially subjective. Adjustment for a measure of reporting tendency is unlikely to abolish this effect because reporting tendency is impossible to measure precisely. Relations with objective outcomes are more suggestive of important effects.” (Macleod et al. 2002 (2))


From the review of the literature so far, we should be careful as to just what measures we can usefully employ based on the information obtained. (Strauss & Corbin 1990). Some of the papers reviewed seem to make quite definite claims about the failure to extract any hard evidence that treatment of anxiety and depression changes the eventual outcome of post-myocardial infarction rehabilitation and have been derogatory about those papers which purport to make claims that show that there is a relationship. Conversely, there are the papers that do seem to show a relationship that point to reasons why the papers that don’t show it are wrong.
In the review we have attempted to be critical in the analysis of the papers and to discuss the shortcomings of each paper concerned. On balance, there would appear to be a consensus that anxiety and depression are independent risk factors for a recurrence of cardiovascular events. It follows that mechanisms to reduce anxiety and depression may well  help to minimise the recurrence rate, but we have not found any unequivocal evidence to support this.

The role of the specialist nurse in cardiac rehabilitation is outlined in the national service framework. We can point to the fact that the specialist nurse is a crucial factor in the delivery of many of the targets.  The paper by Bradley (et al 1999) is a fascinating case study of the interactions between the various healthcare professionals in relation to the provision of post-myocardial infarction rehabilitation programmes. In the specific context of this article we note that the specialist practice nurse was given the opportunity to provide feedback about how they felt that their role could be optimised within the role of the whole concept of rehabilitation. Their recommendations are worth quoting verbatim:
1. Status within the primary healthcare team must be developed

2. Training must address knowledge and skills of cardiac assessment, and drug use and adherence, as well as facilitating behaviour change in relation to lifestyle

3. Opportunity must be given for nurses to give continuity of care

4. Improved integration at the primary-secondary care interface needs to take place, with secondary care staff clearly recognising the role of the practice nurse

One would hope that in the more modern practices that many, if not all, of these requirements are already being met, however, they serve as a very useful template for all those working in the field of post-myocardial infarction rehabilitation.
The paper by Dalal & Evans (2003) shows the value of the nurse in the administration and delivery of a seamless and comprehensive post-myocardial infarction rehabilitation package. In this discussion we are looking primarily at the role of the specialist nurse in the management of anxiety and depression related sequelae, but we must not forget that the rehabilitation package contains many more factors than these two.  The continuity of message delivery about smoking cessation, weight loss, BMI maintenance, dietary control, cholesterol reduction, frequent hypertension checks and the importance of compliance with medication regimes must all be part of the rehabilitation message.

The experienced healthcare professional - be it nurse, doctor or other, - will be aware that over zealous or perhaps injudicious pedantry on these particular issues may very well generate further anxiety. It is therefore a matter of considerable skill and judgement, to try to deliver the appropriate messages in a professional, but not anxiety provoking fashion. (Schwarzer 1992). Patient empowerment comes from patient education. Patient empowerment is one of the most useful tools when it comes to rehabilitation issues. The patient who has been given the means, knowledge and understanding of their condition is far more likely to comply with the rigours of a rehabilitation regime than the patient who feels that they are no more than another statistic. (Rollnick et al.1992)
This concept is given further credence in the paper by Bradley (et al.1999). As healthcare professionals we may feel a sense of detachment from the patient’s immediate dilemma - which in many respects may be essential in order to make clear evidence-based judgements. It is always important however, to be able to empathise with the patient in order to more fully tailor any rehabilitation programme to their perceived needs. The authors produce an extraordinarily perceptive paragraph which should be required reading for any healthcare professional in the field:

Initially patients described their astonishment at surviving a heart attack, which they had previously understood to be a fatal event, and therefore defined their own event as necessarily mild. In the period immediately after the heart attack, the information provided to patients by practitioners apparently encouraged this view of heart attack as a self limited episode from which complete recovery was probable, with little reference to the continuing underlying disease processes. At this stage lifestyle change seemed to be understood by patients as being linked to recovery in the short term rather than a long term preventive measure.
At a later stage patients' understandings about heart attack were subject to change particularly in cases where experience of recovery did not reflect the information given. For example, information encouraged patients to believe that they would be able to have sex in 2-3 weeks, would be back to work in 6 weeks, and would be back to normal within 3 months, when this was often not the case. At this later stage, faith could be lost in "official" information from practitioners and evidence drawn instead from personal experience. Conflict between the two was associated with questioning the explanatory power of information from practitioners, and viewing the adoption of long term lifestyle change as action that would not guarantee protection from a further heart attack.

The programme thus found that patients' understandings of heart attack are closely linked to their attitudes to the potential of lifestyle change to keep them well. The failure of the intervention to acknowledge that the occurrence of heart attack, the severity of heart attack, and the natural history of recovery from heart attack cannot be accounted for entirely by lifestyle seemed to be a central feature in patients' understanding. (Wiles R.  1998)
When we look at the Frasure-Smith paper (1995) and the Davies paper (et al.1999), we can see the prognostic value of anxiety and depression. The experienced healthcare professional  will be aware that these clinical states may not always be obvious. The “positive attribute of stoicism” of the grandmother referred to in the opening paragraph of this article typifies the stiff-upper-lip and “mustn’t grumble” attitude of many of the older generation who will regard it as a mark of weakness to present with overt symptoms of either anxiety or depression, and may well frequently mask the tell-tale verbal constructions or nuances of behaviour that may reveal an underlying problem. We should consider it a legitimate part of the rehabilitation specialist nurse’s remit to be prepared to ask explicit and sympathetically structured questions designed to elicit an appropriate response if any form of psychopathology is realistically considered. (Mayou 1996) We have to ask ourselves if there is actually anybody who wouldn’t feel a degree of anxiety and depression having known that they have just experienced a heart attack.

Part of that question is answered in a paper by Campbell (et al. 1998) the authors point out that part of the reason that there appears to be such disparate information about the levels of anxiety post-myocardial infarction is the fact that the different studies look at anxiety levels at different times after the event. Anxiety is said to peak directly after the event and then subsides quite quickly as the patient  realises that they are not just about to die and that rehabilitation may well help them to resume a normal life (Grimshaw 1993). Hospital studies therefore will tend to record higher levels of anxiety and depression than community based studies by virtue of the fact that they will tend to be dealing with their patients at a point on the timeline that is much nearer the original event than those studies that are carried out in the community which, almost by definition, will be past the anxiety peak. (Wiles 1997)

In terms of recommendations for the development of practice, education and research we can cite the paper by Bradley (et al 1999) where the nurses themselves evaluated the situation and produced four major recommendations, all of which were perfectly sound and, by inference, could apply to the majority of specialist rehabilitation nurses across the country. They felt that their status needs to be developed within the primary healthcare team. Training is always an issue with any healthcare professional and the nurses were quite right to flag up the fact that if they are required to perform a specialist role then it is only proper that they should have specialist training to allow them to fulfil that role professionally. The last two points are fundamental not only to this particular aspect of care, but to most aspects of primary health care continuity of care is essential for optimal management of the patient and that the hospital-based nurse must  communicate adequately with their colleagues in primary care.

With regard to education, the provision of courses for the specialist nurse in this field is perhaps the best option. The exercise of this critical review is one such useful option of education. The possibility of research is a vast field in itself. The reading of the papers necessary to complete this article revealed that the knowledge in this area is far from complete, with many poorly constructed studies diluting the findings of the well constructed ones. Throughout this article we have been at pains to point out the areas that could be usefully addressed by further research.


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