Psychological distress after a heart attack emerges as a critical risk factor for heart health

Many people experience one or more types of psychological distress, including depression, anxiety, psychosocial stress or post-traumatic stress disorder (PTSD), after a heart attack, which can affect their physical recovery and long-term heart health, according to a new American Heart Association scientific statement, published today in the American Heart Association’s flagship, peer-reviewed journal Circulation.

The scientific statement, “Post-Myocardial Infarction Psychological Distress,” describes the prevalence of psychological distress after a heart attack and its significance. The statement also suggests treatment options and behavioral changes for heart attack survivors and health care professionals to improve emotional well-being and overall health.

Psychological distress after a heart attack is quite common but often goes unrecognized. We often focus on the physical aspects of heart disease, yet psychological health is linked to physical health, so when a major cardiac event like a heart attack occurs, emotional recovery is just as important.”

Glenn N. Levine, M.D., FAHA, Chair of the scientific statement writing group, American Heart Association volunteer and professor of medicine at Baylor College of Medicine, Houston

Link between psychological distress and heart health

Psychological distress in people with cardiovascular disease is increasingly acknowledged as both a contributing factor to the development of cardiovascular disease and as a consequence of the condition. A 2021 American Heart Association scientific statement highlighted the connection between psychological health and cardiovascular health and suggested regular mental health screening for people with or at risk for cardiovascular disease. This new statement suggests that post-heart attack depression could be formally characterized as a cardiac risk factor, similar to more traditional risk factors for heart disease, such as high blood pressure or Type 2 diabetes.

According to the new scientific statement:

• An estimated 1 in 3 heart attack survivors (33%) develops depression annually, compared to less than 1 in 10 (8.4%) of U.S. adults in the general population.
• Anxiety and stress may affect up to 50% of heart attack survivors during hospitalization and persist in 20% to 30% of people for several months or more after hospital discharge.
• Those at higher risk for experiencing psychological distress after a heart attack include: people living alone; of female sex, unmarried, unemployed or an immigrant to the U.S.; lacking social support; or having a history of mental health conditions or chronic illness.

Depression, anxiety, psychosocial stress and post-traumatic stress disorder (PTSD) after a heart attack are also associated with a significantly increased risk of cardiac events and death compared to heart attack survivors without any of these conditions. Previous studies have found that:

• People with post-heart attack anxiety are 1.3 times more likely to experience another heart attack or death, and

• Depression and PTSD after a heart attack are both associated with twice the risk of recurrent cardiovascular events or mortality.

Biological and behavioral connections

Damage to the heart muscle from a heart attack can trigger inflammation, which can cause hormonal shifts and brain chemistry changes that may contribute to symptoms of depression, anxiety or PTSD, according to the new scientific statement. Acute psychological stress can cause narrowing of the heart’s arteries (coronary vasoconstriction), reduced blood flow to the heart (ischemia) and irregular heart rhythms (arrhythmia), even in people without previous heart issues.

In addition, multiple studies have confirmed that chronic stress triggers the body’s fight-or-flight response, raising blood pressure and inflammation in blood vessels-factors that may help explain the two-way link between psychological and heart health. The statement notes that some studies have found that up to 70% of people with heart disease experienced reduced blood flow in response to psychological stress.

Some emotional responses, like fear, frustration or temporary sleep disruptions, can be a normal reaction after a major medical event such as a heart attack. However, persistent symptoms, such as sadness, hopelessness, excessive worry or avoidance behaviors, may signal clinical depression, anxiety or PTSD. Financial stress due to missing work or concerns about health care costs or health insurance coverage may increase hormonal stress responses and potentially cause heart disease to worsen. Some people may develop “cardiac anxiety,” an intense fear of having another heart attack.

Psychological distress can also affect healthy lifestyle behaviors that impact physical and physiological recovery. There is substantial evidence that depression after a heart attack is linked to poor sleep, unhealthy eating, physical inactivity and smoking cigarettes, all factors that increase the risk of future cardiac events. Heart attack survivors experiencing psychological distress may also withdraw socially, not take medications as prescribed and/or avoid participating in a cardiac rehabilitation program.

Recognizing and treating psychological distress

According to the statement, it remains unclear whether all people recovering from a heart attack should be formally screened for psychological distress. However, even when formal screening tools aren’t used, checking in on the patient’s emotional well-being is a critical part of follow-up care. Health care professionals are encouraged to be alert to signs of psychological distress in patients after a heart attack.

“A little support can go a long way,” Levine said. “Having a heart attack is a traumatic event, and recovery often includes mental processing of the event and regrouping. Acknowledging to a patient that they may be stressed or depressed after a major cardiac event, and a gentle offer to refer them to a mental health professional for support can be of great benefit. Supporting patients and referring to mental health care can have positive psychological and health impacts for patients and their families.”

There are various options available to help heart attack survivors experiencing psychological distress improve their psychological health, emotional well-being and quality of life. Evidence-based treatments for people with post-heart attack psychological distress include cognitive behavioral therapy, medications, mindfulness-based stress reduction strategies and healthy lifestyle changes, such as regular exercise and improved sleep.

Several clinical trials of antidepressants have found that selective serotonin reuptake inhibitors (SSRIs), a specific class of antidepressant medication, are considered safe and effective for treating depression in people with cardiovascular disease. SSRIs can significantly improve mood in people who have recently had a heart attack or those who have chronic heart disease. More research is needed on other mental health medications to understand which are safe and effective after a heart attack.

The statement notes that cardiac rehabilitation programs are a valuable but often underutilized resource among heart attack survivors. In addition to a structured physical exercise regimen to regain physical strength, cardiac rehab programs often include mental health screening, stress management education and referrals for therapy.

Recent research has confirmed that:

• Patients who participate in cardiac rehab after a heart attack have reduced symptoms of depression, anxiety and stress, and

• These reductions have been associated with improved cardiac outcomes for heart attack survivors. 

However, despite the proven benefits of cardiac rehabilitation, referral rates remain low and less than 20% of eligible patients participate in cardiac rehab programs. The most common barriers patients cite for not participating include transportation challenges, scheduling issues and lack of available programs, particularly in under-resourced communities.

Interventions to support patients with psychological distress, such as cognitive behavioral therapy, medication and mind-body strategies, like yoga and meditation, are confirmed to improve emotional well-being and reduce stress. More research is needed to confirm their impact on long-term cardiovascular risk. The statement calls for more research to confirm whether treating psychological distress can improve cardiovascular outcomes.

“Therapy, medication, lifestyle changes and cardiac rehabilitation programs remain essential tools for holistic, patient-centered care that can improve psychological health and quality of life after a heart attack,” Levine said.

One survivor’s story

Erika Livingston, a marketing professional who lives in Dallas, experienced a heart attack when she was 41 years old. Although she ate a healthy diet and lifted weights regularly, she woke up one morning with severe chest pain that radiated to her back. Once examined in the ER, she was told she was having a heart attack. A cardiologist determined one of her heart’s arteries was 75% blocked, and she had emergency surgery to insert a stent to restore blood flow to her heart.

“The aftermath of my heart attack was traumatic. For more than a year, I couldn’t sleep because I was afraid of having another heart attack and worried the stent might fail,” she said.

After her heart attack, Erika attended cardiac rehabilitation for six weeks to learn how to exercise safely again. However, her cardiac rehab program did not include mental health screening and support. When she continued to experience high levels of anxiety and stress two years after her heart attack, she decided to attend counseling sessions with a trauma expert to help her cope.

“I wish I had sought mental health counseling right away. I needed help learning how to guide myself to a better mental place where I was not continuously worried about another heart attack or worse,” she said.

In addition to participating in cardiac rehab and securing mental health counseling, Erika, a self-described workaholic, drastically cut back her work hours and eliminated a lot of stress from her busy life after her heart attack. Now, she regularly meditates and does yoga to help manage stress. She also sees her cardiologist for follow-up care once a year to make sure the stent is still working and allowing proper blood flow.

“When something traumatic like a heart attack happens, you think ‘What if I don’t make it? What if it happens again?’ Counseling really helped ease my anxiety. I feel much stronger mentally and I sleep amazing now. I’m at peace knowing I’m under great medical care.”

She added, “While I know another heart attack is a possibility and eventually the stent may need to be replaced, I am now able to cope and give myself mental space to process and take the steps I need to stay healthy, every day and long-term,” she said.

This scientific statement was prepared by the volunteer writing group on behalf of the American Heart Association’s Stroke Council; Council on Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; Council on Quality of Care and Outcomes Research; Stroke Council; and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. American Heart Association scientific statements promote greater awareness about cardiovascular diseases and stroke issues and help facilitate informed health care decisions. Scientific statements outline what is currently known about a topic and what areas need additional research. While scientific statements inform the development of guidelines, they do not make treatment recommendations. American Heart Association guidelines provide the Association’s official clinical practice recommendations.