Psychological Distress After Heart Attacks Linked to Increased Risk of Future Cardiac Events

Psychological distress affects an estimated 33-50% of heart attack survivors and significantly increases their risk of future cardiac events, according to a new scientific statement from the American Heart Association published in Circulation. The statement emphasizes that depression, anxiety, psychosocial stress, or post-traumatic stress disorder (PTSD) following a heart attack can impact physical recovery and long-term heart health, with those experiencing persistent psychological distress for up to 12 months being nearly 1.5 times more likely to have another cardiac event.

The connection between psychological health and cardiovascular health has been increasingly acknowledged, as highlighted in a 2021 American Heart Association scientific statement. This new statement suggests that post-heart attack depression could be formally characterized as a cardiac risk factor, similar to traditional factors like high blood pressure or Type 2 diabetes. An estimated one in three heart attack survivors develops depression annually, compared to less than one in ten adults in the general U.S. population.

Those at higher risk for psychological distress include people living alone, females, unmarried or unemployed individuals, immigrants to the U.S., those lacking social support, or those with a history of mental health conditions or chronic illness. Depression, anxiety, psychosocial stress, and PTSD after a heart attack are associated with a significantly increased risk of cardiac events and death. Previous studies found that people with post-heart attack anxiety are 1.3 times more likely to experience another heart attack or death, while depression and PTSD are both associated with twice the risk of recurrent cardiovascular events or mortality.

Biological and behavioral factors explain this link. Damage to the heart muscle can trigger inflammation, leading to hormonal shifts and brain chemistry changes that contribute to symptoms of depression, anxiety, or PTSD. Acute psychological stress can cause coronary vasoconstriction, reduced blood flow to the heart, and irregular heart rhythms. Chronic stress triggers the fight-or-flight response, raising blood pressure and inflammation in blood vessels. Some studies found that up to 70% of people with heart disease experienced reduced blood flow in response to psychological stress.

Psychological distress can also affect healthy lifestyle behaviors, such as poor sleep, unhealthy eating, physical inactivity, and smoking, all of which increase the risk of future cardiac events. Survivors may withdraw socially, not take medications as prescribed, or avoid cardiac rehabilitation programs. Financial stress due to missed work or concerns about health care costs may exacerbate hormonal stress responses and worsen heart disease.

Evidence-based treatments for psychological distress include cognitive behavioral therapy, medications like selective serotonin reuptake inhibitors (SSRIs), mindfulness-based stress reduction strategies, and healthy lifestyle changes. Cardiac rehabilitation programs, which include mental health screening, stress management education, and therapy referrals, are valuable but underutilized, with less than 20% of eligible patients participating due to barriers like transportation challenges, scheduling issues, and lack of available programs.

The statement calls for more research to confirm whether treating psychological distress can improve cardiovascular outcomes, but current interventions are essential for holistic, patient-centered care that improves psychological health and quality of life after a heart attack.