In my current nursing practice, I am by title a Chest Pain Program Coordinator and my facility is an accredited Chest Pain Center with PCI. My job in part, is developing, implementing and maintaining a cost a effective system of care for heart patients and their families thought the continuum of care. I also serve as a leader for performance improvement initiatives specific to the program, develop and implement plans for assuring delivery of goal directed nursing care though the use of the nursing process with patient safety as the primary goal to this population. So, obviously, I chose to focus on a quality improvement initiative study for the cardiac patient and more specifically, the post myocardial infarction (MI) patient and how depressive symptoms are associated with in-hospital complications following acute myocardial infarction (AMI). In this article, the focus was how depressive symptoms are associated with in-hospital complications which in turn effect the length of stay of post MI patients. In previous research, the focus was the long term effect of depressive symptoms on these patients, little research was done on the effect acute care setting.
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The need to understand and control depressive symptoms after an acute myocardial infarction (AMI) is an important preventive intervention. “Depressive symptoms are common after acute myocardial infarction and are associated with a slight increase in risk of in-hospital catheterization and angiography and readmission because of cardiac complications.” It has been reported by multiple studies that the prevalence of depressive symptoms after AMI “range from 15-32%”.
The prevalence of depressive symptoms post AMI is high and impacts healthcare and quality of life. It is recommended to screen for depressive symptoms and begin treatment if identified. Implementing ways to prevent depressive symptoms will decrease cost of hospital re-admissions. Results of recent publication support the need for further studies to “determine more precisely the prognostic impact of post-AMI depressive symptoms” (Lauson, Beck, Huynh, Danielle, (2003).
The admission process at the Ascension health care system has a depression screening. It is to be completed on each admission. If the patients are at risk the nurse notifies the prevention team listed on the screening page. The team will evaluate the patient further to determine if treatment needs to be initiated. This supports the clinical significance that nurses can be effective in identifying depression, not just after an AMI, it can be identified with each patient. This study sparks the question if screening should be done more often throughout the hospital stay as well as on follow-up by care coordinators.
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Reference
Reference:Lauson, C., Beck, C. A., Huynh, T., Dion, D., & al, e. (2003). Depression and prognosis following hospital admission because of acute myocardial infarction. Canadian Medical Association. Journal, 168(5), 547-52. Retrieved from https://search-proquest-com.ezproxy.fhsu.edu/docview/204808216?accountid=27424
I agree Catherine, it does raise the question if screening should be reevaluated throughout the hospitalization or if the patients receive screening after discharge and upon their return to an outpatient cardiac rehab. Also, more knowledgeable health care teams educated about the association with AMI and depressive symptoms is equally as important, nurses are very effective in identification, but other team members should feel empowered to share their observations with the primary nurse or physician.
Christan, great topic. I just took care of a gentleman who had an AMI a year ago, he was working on his house in the heat of the day. Can’t remember where you live, but in K.C. it’s hot with low humidity, just plan hot. He walked into the fire station and said he was feeling dizzy after he came inside. He was anxious because he had an AMI a year ago. I get it, it is scary and with cardiac patients we have to be very careful. He was transported to the hospital and discharged with nothing found after tests were ran. This is a fascinating topic, because it is a real scare and can cause some anxiety and insecurity. In an article published in The American Heart Journal, it was mentioned that 1 in 4 patients experienced recurrent chest pain after having an AMI. This includes non-cardiac chest pain, angina after MI, or another MI. There is still a component of mental health with patients after they have an Mi.
Qintar, Spertus, Tang, Buchanan, Chan, Amin, & Salisbury. (2017). Noncardiac chest pain after acute myocardial infarction: Frequency and association with health status outcomes. American Heart Journal, 186, 1-11.
It is interesting that we are all aware that some AMI patients suffer from depressive symptoms, but I don’t think we ever really know what the exact association is. During my research, I found an (old) article that hypothesized the association. It found that a possible explanation for this association may be that these subjects have been sensitized by the experience of observing the same illness in their relatives along with its likely complications including long term disability and death the close knit family ties in our socio-cultural setting may further contribute to this effect. Also that Type A behavior traits were found significantly associated with symptoms of depression and/or anxiety following AMI and this has also been supported by previous studies. Type A individuals are well known for their competitive, ambitious and fast pace of life and it is likely that the forced period of compulsory bed rest following AMI is incompatible with their habitual life style and promotes further stress, which can present symptoms of depression and anxiety after AMI. Further as a consequence of their personality traits, these individuals are more likely to worry excessively about likely complications of AMI, uncertainties about the future etc and thereby become more prone to symptoms of depression and anxiety after AMI. Another possible explanation may be that the subjects reporting job stress may be already burdened with extra stress at work and the occurrence of AMI brings about an extra burden.Additionally, the study showed the lack of confiding relationships and symptoms of depression and/or anxiety after AMI were found to be significantly associated. Medical teams dealing with patients suffering from AMI need to be aware of these factors in order to assess and manage these patients in a more holistic way.
Muhammad Saleem Akhtar, S. B. (2008). Psychosocial factors associated with symptoms. Pakistan Journal of Medical Sciences, 192-197.
After looking into your topic I found that “AMI patients with depression have an approximate two to four fold risk of mortality compared to non-depressed patients(Hmar & Bhagabati, 2017).” Understanding how depressive symptoms correlate with in-hospital complications is the first step in working towards implementing interventions to reduce associated risk factors. Does your facility currently screen for depressive symptoms? If so, at what intervals do these screenings occur? My unit screens for depressive symptoms upon admission and then reassessments are required at every shift. Even with these screenings I am unsure if my facility is able to further evaluate and treat issues if they come up due to lack of resources for consultation within the hospital setting. Do you have measures to provide treatment during the patient’s hospital stay?
Hmar, B., & Bhagabati, D. (2017). Study of prevalence of depression and impact of depression in patients following acute myocardial infarction. Open Journal of Psychiatry & Allied Sciences, 8(1), 29. doi:10.5958/2394-2061.2016.00035.5
Jennie, I am not currently aware of any standardized nursing assessment at my facility that screens patients, AMI or otherwise for depressive symptoms which I find interesting given the well known association of AMI and depression and possible increase in morbidity and mortality of this population. I would be interested to learn more about how your facility screens these patients, what screening tool do you use? Is it only for AMI patients or do all admitted patients get screened? Do other interventions get put into play if there are suspected depressive symptoms, for example does it reflex a mental health or chaplain consult, does care management find resources available after discharge?
“Myocardial infarction (MI) is a severe life event that is accompanied by an increased risk of depression” (Larsen, 2013). A study I found stated that, “Three months after having suffered MI, about one fifth of the patients in our study had depression according to the Hospital Anxiety and Depression Scale (HADS)” (Larsen, 2013). I would be interested to learn more about this particular scale and determine if it is an effective tool and screening for Depression. This study also questioned whether or not individuals who displayed some depressive tendencies through this screening would benefit from initiation of an anti-depressant? At the time of the study information regarding this question was lacking.
Larsen, K. K. (2013). Depression following myocardial infarction–an overseen complication with prognostic importance. Danish Medical Journal, 60(8). Retrieved July 12, 2018.
There was a study published in 2018 that assessed whether a clinical co-diagnosis of depression and/or anxiety decreases the likelihood of revascularization among STEMI hospitalizations after reviewing stemi hospitalizations from 2004-2013 using data from the Nationwide Inpatient Sample. The findings of the study were “the odds of in-hospital mortality were lower among STEMI hospitalizations with a clinical co-diagnosis of depression and/or anxiety as compared to those without. Our secondary findings confirmed that clinical diagnoses of depression and/or anxiety were less prevalent among revascularized as compared to non-revascularized STEMI hospitalizations. However, the percentage of clinical diagnoses of depression and/or anxiety among STEMI hospitalizations increased at a similar rate over a 10-year period irrespective of revascularization status. To our knowledge, this is the first study to document and examine the “depression paradox” among a population of cardiac patients. These results add to the evidence suggestive of the severely under diagnosed mental health issues surrounding major cardiovascular events, and indeed, chronic disease as a whole” (Pino, E., Zuo, Y., Borba, C., Henderson, D.C., & Kalesan, B., 2018). From the meta analysis, this study supports that the rates of depression after a myocardial infarction increase. however, there is a higher co relation of depression when the outcomes after an MI cause non revascularization, with the need of additional interventions like coronary artery bypass graft (CABG). It is also interesting to note findings that patients who already had a diagnosis of depression prior to an MI event had lower mortality rates.
Resources:
Pino, E., Zuo, Y., Borba, C., Henderson, D.C., & Kalesan, B. (2018). Clinical depression and anxiety among ST-elevation myocardial infarction hospitalizations: Results from Nationwide Inpatient Sample 2004–2013. Psychiatry Research, Volume 266, Pages 291-300. Retrieved from: https://doi.org/10.1016/j.psychres.2018.03.025
This was very interesting to me. I never considered depression of MI patients or during or after MI and recovery as a risk factor for poor outcomes. As I began researching, I found many sources that report the same information about the increased mortality of patients post-MI with depressive disorders.
In a 2016 observational study, 374 Acute Coronary Syndrome patients completed questionnaires related to particular vulnerabilities (life events, cognitive distortions, Type D personality) at the time of hospitalization and at 3, 6, 9 and 12 months post-hospitalization. The study found that these theoretical vulnerabilities predicted depression trajectories which could indicate a potential “chain of events” post-ACS that would enable clinicians to predict those at risk of poorer outcomes after ACS treatment (Keegan, 2016).
The article also refers to meta-analysis of 10,175 post-MI clients in which depressive symptoms indicated 32% higher risk of mortality, consistent with this smaller observational study.
With the light being continually shone on our country’s lack of mental health services, this is just one more area that mental health plays a key role in our physical health.
Keegan, C., Conroy, R., Doyle, F. (2016). Longitudinal modelling of theory-based depressive vulnerabilities, depression trajectories and poor outcomes post-ACS. Journal of Affective Disorders, 191. Retrieved July 14, 2018.