Psychosocial factors related to unrecognized acute myocardial infarction

Why is it Important to Assess and Treat Alexithymia in the Cardiologic Field? An Overview of the Literature

Background

Alexithymia has been found to be associated with several somatic illnesses, such as cardiovascular, indicating that it might be a risk factor for early death in the long-term course of post-myocardial infarction. From the cardiology perspective, the aim was to collect current evidence about the relationship between alexithymia and somatic illness.

Methods

The literature was synthesized and summarized in a narrative format. The literature search was carried out in PubMed. Pertinent studies published in the last 50 years written in English were included and organized by three main topics ("The relation between alexithymia and somatic illness from the cardiology perspective"; "How do assess alexithymia?"; "Treating alexithymia") to be discussed.

Results

High alexithymia is a dimensional trait that affects around 10% of the general population and up to 55% of people with essential hypertension. Also, the link between alexithymia and cardiovascular activity has been pointed out. There are several validated tools to assess alexithymia, as well as treatment options.

Conclusion

Knowledge about the main features of alexithymia, as well as its assessment and treatment, can promote a multifactorial approach to the primary, secondary, and tertiary prevention of cardiac diseases.

Alexithymia for cardiologists: a clinical approach to the patient

Alexithymia literally meaning 'no words for emotions' is a term used in mental health settings to describe people who have difficulties in identifying and verbalizing their emotional states. There is evidence in the literature that this personality trait may influence negatively the illness behavior when an acute coronary event occurs. In fact, people with high alexithymia are more likely to experience wrong appraisal and interpretation of symptoms, and because of their difficulty in describing feelings to others, they can be poor in reporting symptoms at the first consultation with a physician. This behavioral pattern (alexithymic) may put patients with acute myocardial infarction at higher risk for delayed medical care. Here, we aim to present an overview of alexithymia from the perspective of the clinical cardiologist, with a focus on the definition, clinical recognition, and potential impact on cardiovascular health.

Surviving to Acute Myocardial Infarction: The Role of Psychological Factors and Alexithymia in Delayed Time to Searching Care: A Systematic Review

The time from symptom onset to reperfusion is a critical determinant of myocardial salvage and clinical outcomes in patients with acute myocardial infarction (AMI). This time period could be delayed if people do not seek help promptly and/or if the health system is not efficient in responding quickly and attending to these individuals. The aim of this study was to identify psychological factors associated with pre-hospital delay (PHD) or patients’ decisional delay (PDD) in people with an ongoing AMI. A search in PubMed/Medline from 1990 to 2021 with the keywords “pre-hospital delay” OR “prehospital delay” OR “patient delay” OR “decisional delay” OR “care seeking behavior” AND “psychological factors” OR “alexithymia” AND “myocardial infarction” was performed. Thirty-six studies were included, involving 10.389 patients. Wrong appraisal, interpretation and causal beliefs about symptoms, denial of the severity of the symptoms and high levels of alexithymia were found related to longer PHD or PDD. Alexithymia may be an overarching construct that explains the disparate findings of the studies exploring the role of psychological factors in PHD or PDD. Further studies are needed in order to analyse the role of alexithymia in patients with risk factors for AMI to prevent delay.

Influence of alexithymia on the management of Latin American patients with asthma: A cross-sectional study

Objectives:

In asthmatic patients, studies suggest that alexithymia leads to negative consequences and emotions that can affect physical, psychological, and social aspects of life. We designed this study to determine the frequency of alexithymia in Latin American patients with asthma, as well as to understand how this personality trait and each of its components interact with asthma severity and demographic variables, and their implications on treatment adherence and disease control under such setting.

Methods:

We conducted a cross-sectional study, involving 265 Latin American patients with asthma. Patient demographics and clinical characteristics were reported. The presence of alexithymia, asthma severity, and control, as well as treatment adherence, was analyzed. To assess the presence of alexithymia, the 20-item Toronto Alexithymia Scale was used. For the statistical analyses, we performed Kendall’s tau-b correlation coefficient, chi-square tests for association, and one-way analysis of variance.

Results:

A total of 265 patients participated in the study with a gender distribution of 69.4% female and an average age of 54.7 years. In total, 30.2% of individuals presented alexithymia. There was a statistically significant correlation between educational level and 20-item Toronto Alexithymia Scale categories (p < .001), as well as a higher proportion of severe (35.1%, p = .001) and uncontrolled (50.0%, p = .185) asthma in patients with alexithymia. A higher proportion of patients with some level of non-adherence was seen on those with uncontrolled asthma (68.5%, p = .008).

Conclusion:

Our results suggest that in our sample, 3 in 10 Latin American asthma patients have alexithymia, and such mental condition is more common in those individuals with lower educational levels. Individuals with alexithymia present with severe asthma more frequently than do patients with possible or no alexithymia and are also more likely to have their disease uncontrolled.

Determinants of cardiovascular disease and sequential decision-making for treatment among women: A Heckman's approach

•

Women over age 40, from lower socio-economic status and those widowed/divorced are at elevated risk.

•

Diabetes, hypertension, obesity and unhealthy diet are the major risk factors.

•

Treatment-seeking is higher in women over age 40, from upper socio-economic status and those married.

•

Autonomy, accessibility, affordability and availability influence treatment-seeking behaviour.

Assessing the Reliability of Four Standard Health Measures in a Sample of Older, Urban Adults

Increasing attention is being paid to racial and ethnic differences in the structure and measurement of physical health and mental health constructs. The objective of this study was to examine the reliability of four measures of physical health and mental health in a sample of 400 older (50+ years) African Americans and Caucasians. These measures are the instrumental activities of daily living and activities of daily living scales of the National Chronic Care Consortium Health Risk Appraisal Survey, the SF-12, the Multidimensional Health Locus of Control Scale, and the John Henryism Active Coping Scale. The measures were tested by racial group. The results of factor analyses reveal that the overall reliability of each scale, as measured by Cronbach’s alpha, was near or above .70. However, the item-to-scale correlations of many of these scales were low. This finding indicates that the measurement of the constructs may be different for older African Americans and Caucasians.

Alexithymia affects pre-hospital delay of patients with acute myocardial infarction: meta-analysis of existing studies

Background:

The time between the onset of symptoms and reperfusion is a critical determinant of the clinical course of patients with acute myocardial infarction (AMI). Any delay in seeking help will affect patient’s outcome. Alexithymia can influence the information processing but also the skills to detect the signal of an ongoing AMI.

Method:

Systematic review and meta-analysis of studies investigating the role of alexithymia in pre-hospital delay after AMI. Pubmed/Medline and PsychINFO/Ovid search from 1990 until 2012.

Results:

Out of 29 studies investigating the role of psychological factors in pre-hospital delay after AMI, 3 studies specifically assessed alexithymia, involving 258 patients. All studies used the Toronto Alexithymia Scale to group patients into clusters by time to presentation after AMI. Meta-analysis of data showed that the patients with higher emotional awareness (i.e., low alexithymia) had shorter time to presentation after AMI.

Conclusions:

Preliminary evidence indicates that alexithymia may have a role in seeking help delay after AMI. Further studies are necessary to better appreciate how alexithymia influence help-seeking in patients with an evolving AMI and in what extent their ineffective behavior can be changed.

A review of interventions aimed at reducing pre-hospital delay time in acute coronary syndrome: what has worked and why?

BACKGROUND

Delay in seeking treatment for acute coronary syndrome (ACS) symptoms is a well recognised problem. While the factors that influence pre-hospital delay have been well researched, to date this information alone has been insufficient in altering delay behaviour.

AIM

This paper reports the results of a critical appraisal of previously tested interventions designed to reduce pre-hospital delay in seeking treatment for ACS symptoms.

METHODS

The search was confined to interventions published between 1986 and the present that were written in English and aimed at reducing pre-hospital delay time. The following databases were searched using keywords: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Pubmed, Academic Search Premier, Ovid, Cochrane, British Nursing Index, and Google Scholar. A total of eight intervention studies were identified as relevant. This review was developed following a systematic comparative analysis of those eight studies.

RESULTS

Seven of the eight interventions were based on mass media campaigns. One campaign was targeted at individuals. All were aimed at raising ACS symptom awareness and/or increasing prompt action in the presence of symptoms. Only two studies reported a statistically significant reduction in pre-hospital delay time.

CONCLUSION

In response to concerns about prolonged pre-hospital delay time in ACS, interventions targeting the problem have been developed. The literature indicates that responses to symptoms depend on a variety of factors. In light of this, interventions should include the scope of factors that can potentially influence pre-hospital delay time and ideally target those who are at greatest risk of an ACS event.

Symptoms of anxiety and depression are correlates of angina pectoris by recent history and an ischemia-positive treadmill test in patients with documented coronary artery disease in the pimi study

Objective. We tested the association of specific psychological characteristics in patients having stable coronary disease with the reporting of anginal symptoms during daily activities, and positive exercise testing. Methods. One hundred and ninety-six patients with documented CAD enrolled in the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study completed an anginal history questionnaire and a battery of psychometric tests. They also underwent standardized exercise treadmill tests. Results. Patients with a recent history of angina were more likely to be female, and had higher Beck Depression (P = .002), State Anxiety (P = .001), Trait Anxiety (P = .03), Harm Avoidance (P = .04) and Muscle Tension (P = .004) scores than patients who had no recent history of angina. Along with several treadmill variables indicating more severe disease state and reduced exercise tolerance, patients who developed angina on a positive treadmill test also displayed higher scores on the Beck Depression Inventory (P = .003) and State Anxiety (P = .004) scales. Conclusions. Several psychological characteristics, and most notably anxiety and depression, are strong correlates of recent angina and angina in the presence of ischemia provoked by treadmill testing.

Subjective well-being as a determinant of individuals' responses to symptoms: a biopsychosocial perspective

BACKGROUND

Although many models have been developed to explain health behaviour, differences in individual response to symptoms remain largely unexplained; moreover, they tend to underestimate affective (i.e., emotional) processes and they neglect the construct of well-being, despite its predominant role in the definition of health.

AIM

The development of a novel conceptual framework to explain and predict variability in individuals' responses to symptoms, through a bio-psychosocial perspective, considering also the potential role of subjective well-being.

MATERIALS & METHODS

The most widely used health behaviour models were being reviewed, as well as their limitations. Based on the evidence in the literature, major domains that influence response to symptoms are identified and analysed.

RESULTS

A new conceptual framework that is not limited to explanation of common health behaviours such as treatment seeking or problem identification, but draws attention to a broad spectrum of individual reactions and experiences following the physical experience of a symptom or medical condition. The role of subjective well-being and its determinants are considered as a central concept in the proposed framework.

DISCUSSION

The present conceptual framework provides a comprehensive bio-psychosocial perspective on behavioural outcomes related to individual response to symptoms.

CONCLUSION

The proposed framework opens a new window to patient centred care. Research to evaluate the proposed framework may improve the quality of clinical care and overall patient satisfaction.

Alexithymia, depression and heart rate in candidates for cardiac surgery

Effects of psychological traits on heart rate (HR) and heart rate variability (HRV) were evaluated in patients awaiting cardiac surgery. Alexithymics demonstrated slowed HR, whereas high cognitive performance was associated with elevated HR in 2-3 days before surgery. Depression negatively correlated with HRV low frequency power. These data are consistent with previous findings of diverse moderate stress effects on HR regulation in cardiologic patients and healthy subjects in accordance to differences in psychological characteristics.

Reducing delay in seeking treatment by patients with acute coronary syndrome and stroke: a scientific statement from the American Heart Association Council on Cardiovascular Nursing and Stroke Council

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Factors influencing migraineur-consulting behavior in a university population

OBJECTIVE

The purpose of this study was to identify factors that contribute to treatment-seeking behavior in migraineurs in a large employer population. Specifically, the impact of psychographic variables, such as social support, attitudes toward medication, locus of control, and migraine-associated disability, are considered concomitantly with demographic and disease severity variables.

BACKGROUND

Migraine remains an underconsulted condition. Previous explorations of demographic factors and headache characteristics have not adequately predicted migraineur physician-consulting behavior.

METHODS

University employees and students experiencing headaches were interviewed by pharmacists to determine whether they suffer from migraine using the International Headache Society (IHS) criteria for migraine. Identified migraineurs were categorized into 3 groups: (1) never-consulter, (2) lapsed-consulter, and (3) current-consulter. Each group was asked to complete an instrument that assesses perceived social support (Headache Social Support Questionnaire), medication attitudes (Beliefs about Medicines Questionnaire), locus of control (Headache-Specific Locus of Control Scale), and migraine-associated disability (Migraine Disability Assessment Questionnaire). Univariate (ANOVA) and multivariate (logistic regression) approaches were used to identify factors associated with migraineur-consulting behavior.

RESULTS

A total of 100 subjects participated in the study. Eighty-two participants met IHS criteria for migraine, of whom 22 were never-consulters, 20 were lapsed-consulters, and 40 were current-consulters. The consulter groups differed on scores acquired from the Social Support Active Involvement subscale (P= .04) and the Healthcare Professional Locus of Control subscale (P= .010). The logistic regression procedures confirmed the contributions of social support and healthcare locus of control in predicting migraineur-consulting behavior.

CONCLUSION

Results suggest that attitudes concerning the role of healthcare professionals and the presence of a supportive social network have greater influence on migraineur-consulting behavior than do patient demographic characteristics, beliefs about medications, and migraine frequency and severity. With an understanding of the link between psychosocial variables and consulting behavior, healthcare professionals may be able to positively impact migraineur physician consultation rates, drug therapy, and quality of life.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke

Patient delay in seeking treatment for acute coronary syndrome and stroke symptoms is the major factor limiting delivery of definitive treatment in these conditions. Despite decades of research and public education campaigns aimed at decreasing patient delay times, most patients still do not seek treatment in a timely manner. In this scientific statement, we summarize the evidence that (1) demonstrates the benefits of early treatment, (2) describes the extent of the problem of patient delay, (3) identifies the factors related to patient delay in seeking timely treatment, and (4) reveals the inadequacies of our current approaches to decreasing patient delay. Finally, we offer suggestions for clinical practice and future research.

Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001

BACKGROUND

Timely access to emergency cardiac care and survival is partly dependent on early recognition of heart attack symptoms and immediate action by calling emergency services. We assessed public recognition of major heart attack symptoms and knowledge to call 9-1-1 for an acute event.

METHODS

Data are from the 2001 Behavioral Risk Factor Surveillance System, a state-based telephone survey. Participants (n = 61,018) in 17 states and the U.S. Virgin Islands indicated whether the following were heart attack symptoms: pain or discomfort in the jaw, neck, back; feeling weak, lightheaded, faint; chest pain or discomfort; sudden trouble seeing in 1 or both eyes (false symptom); pain or discomfort in the arms or shoulder; shortness of breath. Participants also indicated their first action if someone was having a heart attack.

RESULTS

Most persons (95%) recognized chest pain as a heart attack symptom. However, only 11% correctly classified all symptoms and knew to call 9-1-1 when someone was having a heart attack. Symptom recognition and the need to call 9-1-1 was lower among men than women, persons of various ethnic groups than whites, younger and older persons than middle-aged persons, and persons with less education. Persons with high blood pressure, high cholesterol, diabetes mellitus, or prior heart attack or stroke were not appreciably more likely to recognize heart attack symptoms than were persons without these conditions.

CONCLUSIONS

Public health efforts are needed to increase recognition of the major heart attack symptoms in both the general public and groups at high risk for an acute event.

Alexithymia following myocardial infarction: psychometric properties and correlates of the Toronto Alexithymia Scale

OBJECTIVE

The purpose was to explore the psychometrics and correlates of the Toronto Alexithymia Scale (TAS-20) after myocardial infarction (MI).

METHODS

The TAS-20 and other self-report measures were administered 3-6 months after discharge to 1443 patients.

RESULTS

Good internal reliability was confirmed for the total TAS-20 and two subscales (F1 and F2). The F3 showed low internal consistency linked to negatively keyed items. The prevalence of alexithymia was 30.2% at the first interview. Alexithymics were older, less educated, more likely to have previous MIs and had higher scores on all measures of negative emotions. Six-month test-retest reliability was.47 (n=167). Residual change score analysis showed patients with more education and a first MI had greater decreases in alexithymia than expected.

CONCLUSIONS

The TAS-20 has adequate internal consistency in post-MI patients, and its correlates are similar to other reports. Low temporal stability suggests that secondary alexithymia is important after MI.

Psychological factors affecting a medical condition: ischemic coronary heart disease

The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.

A psychobehavioral factor, alexithymia, is related to coronary spasm

The aim of this study was to assess whether the psychobehavioral pattern alexithymia is related to coronary artery spasm. Alexithymia, deficient psychological awareness, was examined using the Minnesota Multiphasic Personality Inventory Alexithymia Scale in 100 patients with angina pectoris in whom coronary spasm, defined as > or = 99% coronary narrowing, was documented upon ergonovine provocation, and in 109 patients with chest pain syndrome who were shown to have almost normal coronaries without inducible coronary spasm on coronary angiogram (control group). Alexithymia was approximately twice as prevalent in the coronary spasm group (31%) as in the control group (14%) (p<0.01). Among various conventional risk factors including hyperlipidemia, obesity, diabetes mellitus, hypertension, hyperuricemia, or family history of ischemic heart disease, only male sex and smoking were more prevalent in the coronary spasm group than in the control group (p<0.001). The odds ratios of coronary spasm adjusted for all the other risk parameters including sex and age were 4.14 [95% confidence interval (CI) 1.81-9.47] for alexithymia and 2.38 (95, CI 1.18-4.82) for smoking. A psychobehavioral pattern, alexithymia, relates to coronary spasm. This relationship is independent of the conventional coronary risk factors.

The structure of emotions during acute myocardial infarction: a model of coping

The present state of medical care for heart attacks, or acute myocardial infarction (AMI), clearly indicates that rapidly and expeditiously seeking definitive medical care will reduce morbidity and prevent mortality. Despite the clearly established advantages of rapid AMI treatment, the time from the onset of acute symptoms of AMI to definitive medical care is often prolonged and individuals with a prior history of AMI and/or coronary artery disease (CAD) extend care-seeking. Behaviors and actions surrounding acute care-seeking are often fraught with complex social, psychological and emotional processes. The purpose of the present paper is to bring together a theoretical and an applied understanding of the interval of time from acute symptom onset to definitive medical care during AMI; and to understand the role of emotions in the care-seeking process. This task is especially important among individuals with a prior history of AMI and/or CHD. These individuals can be seen as experiencing a "spectrum of posttraumatic disturbances", ranging from anxiety to posttraumatic stress disorder and alexithymia. These disturbances contribute to extended care-seeking thereby placing the individuals at greater risk for AMI and sudden cardiac death. Effective intervention requires three elements. First, knowledge is necessary so that individual and lay others can correctly label symptoms and signs of an AMI. Second, it is necessary to provide feasible behaviors that individuals and lay others can use to access definitive medical care. Third, and perhaps most importantly, it is necessary to provide understanding of and skills to cope with the emotional arousal surrounding both the primary traumatic experience of symptoms and signs, potential secondary traumatic consequences of AMI care-seeking and tertiary trauma from the long-term consequences of CHD.

Correlates of unrecognized acute myocardial infarction detected via perfusion imaging

Research using the electrocardiogram (ECG) indicates that about 1/3 of acute myocardial infarctions (AMIs) are unrecognized. To date, no studies of unrecognized AMIs have employed perfusion imaging, although it is more sensitive than the ECG and provides more information about infarct characteristics, such as size and location. In this study, 82 of 258 consecutive patients (31.8%) undergoing exercise testing with technetium-99m sestamibi perfusion imaging had fixed, nonartifactual perfusion defects, suggesting AMI. These patients were interviewed regarding their recognition of AMI; 27 patients (32.9%) had unrecognized AMI. Unrecognized AMI was significantly associated with (1) smaller infarcts, (2) infarcts not in the apical or septal regions, (3) diabetes mellitus, (4) lack of angina, (5) a negative family history for cardiac disease, and (6) being African-American. Many of these variables were significantly intercorrelated, and in multivariate analysis, unrecognized AMI remained significantly predicted by a smaller infarct and lack of angina. This study suggests that the incidence of unrecognized AMI detected via perfusion imaging on a clinic population is similar to that detected via electrocardiographic studies on community samples. This study also replicates prior findings of the medical history and demographic correlates of unrecognized AMI, and indicates that infarct size and location are also associated with unrecognized AMI.

How are alexithymia and physical illness linked? A review and critique of pathways

We review the empirical literature and critique four possible pathways linking alexithymia and physical illness; (a) alexithymia leads to organic disease through physiological or behavioral mechanisms: (b) alexithymia leads to illness behavior (physical symptoms, disability, excessive health care use) through cognitive or social mechanisms: (c) physical illness leads to alexithymia; and (d) both alexithymia and physical illness result from sociocultural or biological factors. Our review suggests that alexithymia is associated with tonic physiological hyperarousal, certain types of unhealthy behavior, and a biased perception and reporting of somatic sensations and symptoms. Alexithymia also appears to influence health care use, but in a complex fashion. Although trauma may give rise to alexithymia, whether physical illness such as chronic pain does so is not known, and there is little evidence that sociocultural or biological factors lead to both alexithymia and physical illness. We conclude that alexithymia probably influences illness behavior, but there is little support for the hypothesis that alexithymia leads to chronic organic disease, especially when one distinguishes organic disease from illness behavior.

Alexithymia and health care utilization

Alexithymia's link with health care utilization is unclear. Alexithymia may be overrepresented among clinical samples because of a proclivity to seek care, or alexithymia may prompt delay or avoidance of care, perhaps exacerbating illness. In 911 young adults, this study examined relationships between alexithymia (Toronto Alexithymia Scale-20; total and three factor scores) and the use of six health services during the past year: outpatient medical treatment, emergency room, hospitalization, psychotherapy, routine dental care, and nonprescription analgesics. Three potential mediators (insurance status, depression, and somatic complaints) were controlled to determine alexithymia's unique relation to utilization. The alexithymic difficulty in identifying feelings was linked to increased use of outpatient treatment, after controlling for potential mediators. Difficulty identifying feelings also was related to the use of psychotherapy and analgesics, but these relationships were accounted for by increased depression and somatic complaints, respectively. The alexithymic preference for externally oriented thinking was independently linked with the decreased use of outpatient treatment, to not having psychotherapy, and to being more likely to obtain preventive dental care. Our results may explain contradictions in the literature; separate alexithymic characteristics have different relationships with different types of health care utilization.