Fear of another heart attack may be a distinct stress factor

Lea en español

Stress after a heart attack is understandable – and new research into what drives such stress suggests that fear of another heart attack might play a significant role.

Understanding how that fear works, and how it is distinct from mental health conditions such as anxiety and depression, is important because it could lead to better care for survivors, said Dr. Sarah Zvonar, a cardiac critical care registered nurse and postdoctoral student at the Indiana University School of Nursing in Indianapolis.

She recently presented the findings at the American Heart Association's Scientific Sessions conference in Chicago. The results are considered preliminary until the full findings are published in a peer-reviewed journal.

Fear of recurrence has been studied more extensively in people with cancer, Zvonar said, but less so in the cardiology realm. She was inspired to look into the topic after watching her father and the fathers of four lifelong friends deal with heart attacks and the worries that followed. The men often asked, "Is this going to happen again?"

To examine such feelings, Zvonar and her colleagues enrolled 171 people who had survived at least one heart attack between November 2021 and December 2022 and gave them a series of surveys to measure stress, anxiety, depression, fear of recurrence and how they perceived their condition.

On average, it had been about six months since the participants' heart attack. The researchers repeated the surveys about six weeks later.

Zvonar's analysis first looked at factors that might predict either fear of recurrence or perceived stress. She found that some factors differed. People who were younger or white tended to be more likely than those who were older or Black to develop fear of recurrence. Fear of recurrence was predicted by the score of how people perceived their condition, which Zvonar said measured things such as their concerns about how long their problems would last or what aspects of it were in their control.

Perceived stress, meanwhile, was predicted by alcohol use and fear of recurrence itself.

When the researchers adjusted the results to take anxiety and depression into account, fear of recurrence remained an independent factor that contributed to stress.

"The people who had more fear of recurrence had an increased level of stress," Zvonar said, and stress can be a "huge predictor" for people to have future heart problems, including potentially another heart attack.

Understanding how fear of recurrence and its related stress are separate from depression or anxiety could affect patient care, she said. Anxiety and depression are long-term mental states that can be treated with medications. But if the problem is fear- and stress-related, those medications might not address the root issue.

Fear of recurrence can be sporadic, Zvonar said. It might appear suddenly, perhaps when someone feels pain during a routine task and wonders, "Is this a heart attack again?" Or it might manifest as a dread of going to the doctor because they are afraid of getting bad news.

Dr. Kim L. Feingold, a cardiac psychologist and the founder and director of Cardiac Behavioral Medicine at Northwestern Medicine Bluhm Heart Hospital in Chicago, said the study's finding that fear about the future would affect someone's stress levels made sense.

"Fear and heightened anxiety trigger our nervous system's stress response to help protect us from a possible threat," which can be a good thing when those emotions are temporary, said Feingold, who was not involved in the new research. But "an abundance of fear or chronic fear can have a negative impact on mood and health."

Many people lose confidence in their bodies after a heart attack, Feingold said, and become unsure how to distinguish benign symptoms from problematic ones. "It's as if our filter that we had always used to interpret the meaning of physical symptoms is no longer valid after a heart attack or a cardiac event."

She likened the emotions to being in a car crash, then having to drive again. "For most, getting behind the wheel again is anxiety-provoking at first but then becomes more comfortable with time."

Working with a health care team can help early on, Feingold said. "While it's not healthy to run to the doctor or ER with every symptom, it is appropriate in the few months after a heart attack to benefit from assistance in interpreting symptoms." For most people, she said, the feedback will speed up the learning curve.

Zvonar acknowledged limits to the study. Most of the participants (69%) were women, and the average age was 39. However, the average age in the United States for a first heart attack is 66 for men and 72 for women. And the roughly six-week period between the two rounds of surveys was relatively brief. Fear of recurrence levels did not fall between the two timeframes, she said.

Future research, Zvonar said, would investigate ways to help survivors cope. "Now that we know that there is this fear of recurrence, what can we do to effectively intervene on the patient, or even the family's behalf?"

She said the medical profession as a whole should address such questions about how to help survivors and families cope with not just physical issues but their mental and emotional concerns.

"I think that we need to be better at answering these questions for them and walking them through what this means for them, and how to make sure they don't just live past this and live a longer life, but have a higher quality of living," Zvonar said.

Find more news from Scientific Sessions.