Secondary Logo

Journal Logo

Gender Differences in Anxiety and Complications Early After Acute Myocardial Infarction

AbuRuz, Mohannad Eid PhD, RN; Masa’Deh, Rami PhD, RN

The Journal of Cardiovascular Nursing: November/December 2017 - Volume 32 - Issue 6 - p 538–543
doi: 10.1097/JCN.0000000000000375
ARTICLES: Symptoms
Free

Background: Anxiety is the earliest psychological response to acute myocardial infarction. When anxiety persists or becomes severe, it has negative consequences including increased risk for in-hospital complications. Therefore, it is necessary to determine which groups of people are at risk for high anxiety after acute myocardial infarction.

Objective: The aim of this study was to determine whether there is a difference in anxiety levels and rate of complications based on gender early after acute myocardial infarction.

Methods: A comparative design was used. Patients with acute myocardial infarction were interviewed within 72 hours (mean [SD], 40 [18] hours) of admission to the hospital and completed a sociodemographic and clinical questionnaire and the Anxiety Subscale of Hospital Anxiety and Depression Scale. In addition, clinical data were abstracted from the participants’ medical record after discharge.

Results: A total of 250 patients, with a confirmed diagnosis of acute myocardial infarction, participated in this study: 163 men and 87 women. Female patients were more anxious (15.5 [3.6] vs 8.1 [2.9], P < .01) and had more complications (1.1 [1.9] vs 0.6 [0.08], P < .05) than male patients did.

Conclusions: Anxiety is a global problem after acute myocardial infarction. Exploration of reasons why women of different cultures are at a higher risk for anxiety after acute myocardial infarction is necessary. It is of high clinical importance to determine strategies for managing anxiety in patients with or suspected to have acute myocardial infarction, especially women.

Mohannad Eid AbuRuz, PhD, RN Associate Professor, College of Nursing, Applied Science Private University, Amman, Jordan.

Rami Masa’Deh, PhD, RN Associate Professor, College of Nursing, Applied Science Private University, Amman, Jordan.

The authors have no funding or conflicts of interest to disclose.

Correspondence Mohannad Eid AbuRuz, PO Box 142, Shafa Badran, Amman, Jordan 11934 (mohannadeid@yahoo.com or m:aburuz@asu.edu.jo).

Cardiovascular disease is a worldwide killer and remains the number 1 cause of death.1,2 Coronary heart disease is the most common manifestation of cardiovascular disease. The estimated prevalence of coronary heart disease in the United States is 15.7 million.2 In the middle east, between 1999 and 2020, the mortality of coronary heart disease will increase by 174% in men and 146% in women.3 This is a greater increase than seen in many other world regions.3 In Jordan, a middle eastern, developing country, cardiovascular disease is the major health problem and leading cause of death, accounting for 35% of all deaths in the country,4 whereas coronary heart disease was responsible for 43 000 (16.8%) deaths in 2012.4

Acute myocardial infarction (AMI) is the primary manifestation of coronary heart disease. Anxiety is the earliest psychological response to AMI.5 Anxiety has been considered both an appropriate and inappropriate response. It is appropriate when it is transient and produces motivation for action. In patients with AMI, a slight increase in anxiety level may stimulate individuals to quickly seek treatment when faced with acute symptoms. When anxiety persists or becomes severe, negative consequences may result including difficulty adhering to prescribed treatments and difficulty making recommended lifestyle changes, increased risk for recurrent acute cardiac events, and increased risk for in-hospital complications after admission for AMI.1

Anxiety is considered a universal emotional response. In a previous study6 about anxiety after AMI, the investigators enrolled 912 patients from a combination of western and eastern cultures including Australia, England, Japan, South Korea, and the United States. The mean level of anxiety in the entire sample was higher than the reference mean level of healthy adults. Moreover, patients reported high anxiety levels in all countries.

The prevalence of anxiety after AMI is high. Seventy percent to 80% of patients with AMI have symptoms of anxiety.7 Moreover, it persists in approximately a quarter of patients with cardiovascular disease.1,8 Ten percent to 26% of patients with AMI had higher levels of anxiety than did patients with a psychiatric disorder.8 Anxiety early after AMI has been associated with complications (ie, reinfarction, recurrent ischemia, ventricular fibrillation, sustained ventricular tachycardia, and in-hospital death). In addition to that, anxiety has been associated with long-term complications such as reoccurrence of AMI and increased mortality and morbidity.9

A further look at studies investigating the effect of anxiety on in-hospital complications showed the following: (a) different studies5,10–17 showed that anxiety increased these complications, (b) some studies showed that anxiety was an independent predictor of these complications after controlling for sociodemographic and clinical variables,5,11,13 (c) 4 studies18–21 showed that anxiety was not associated with the outcomes, and (d) 1 study22 reported that anxiety was associated with a survival advantage.

Determining which groups of people are at risk for higher anxiety scores with AMI will help us implement programs to control the negative outcomes of anxiety. Previous studies23–27 on gender differences regarding anxiety after AMI showed that women tend to have higher anxiety than men do. This finding was consistent across the western and eastern cultures studied.24 Women reported mean anxiety levels 25% higher than those reported by men, and twice as many women as men in the sample reported anxiety in the extreme ranges.24 To the contrary, other investigator have found no difference between genders28–30 possibly because of a small sample size, particularly of women, and low power to detect differences.24 Therefore, the purpose of this study was to determine whether there was a difference in anxiety levels and rate of complications based on gender early after AMI.

Back to Top | Article Outline

Research Hypotheses

  1. Female patients will have higher anxiety scores than male patients will.
  2. Female patients will have a higher complication rate than male patients will.
  3. Anxiety scores will be an independent predictor for complications (for men and women) after controlling for sociodemographic and clinical variables.
Back to Top | Article Outline

Methodology

Research Design, Sample, and Setting

A comparative design was used in this study. The study was conducted at 3 private hospitals in Amman, Jordan. The inclusion criteria were (1) a diagnosis of AMI evidenced by elevated cardiac enzymes, standard electrocardiogram (ECG) changes, and/or chest pain; (2) 18 years and older; (3) hemodynamic stability with no chest pain at the time of interview; (4) no cognitive impairment affecting the ability to answer questionnaires; and (5) no previously diagnosed psychiatric disorder.

To make sure that the sample size was sufficient to detect statistical significance with a medium effect size, a power of 0.80, and a type I error of 0.05, a power analysis based on Cohen power table was conducted.31 The statistical tests were based on mean difference for hypotheses 1 and 2, and regression with 7 independent variables was based on mean difference for hypothesis 3. On the basis of those assumptions, 64 participants were needed for hypotheses 1 and 2, whereas 106 participants were needed for hypothesis 3. Therefore, it was determined that the sample size of 250 was adequate for the planned statistical analysis.

Back to Top | Article Outline

Ethical Considerations

Ethical approval for this study was granted by the institutional review board (IRB) committee at the Applied Science Private University, Amman, Jordan (faculty 005). The principal investigator met with the medical and nursing directors of the previously mentioned hospitals, presented the study proposal, and submitted the IRB approval letter. These hospitals accepted the IRB approval from the Applied Science University. Therefore, permissions to conduct the study within these hospitals were issued to the principal investigators by the medical directors.

Back to Top | Article Outline

Procedure

Research assistants explained the study objectives to the participants. They also assured them that their participation was voluntary and they could withdraw from the study at any time. Then, they were asked to sign an informed consent if they agreed to participate. The research assistants were experienced cardiovascular nurses who collected data from each participant within 72 hours (mean [SD], 40 [18] hours) of admission to the hospital. During the interview, participants completed the sociodemographic and clinical questionnaire and the Anxiety Subscale of the Hospital Anxiety and Depression Scale (HADS). In addition, clinical data were abstracted from the participants’ medical record after discharge.

Back to Top | Article Outline

Measurement of Variables

Sociodemographic and Clinical Characteristics

These data were obtained by research assistants during patient interviews and by reviewing medical records. The following sociodemographic and clinical data were collected: age, gender, marital status, admission vital signs, medications used during hospitalization, and history of hypertension, diabetes, previous myocardial infarction, previous angina, smoking, coronary artery bypass graft, percutaneous transluminal intervention, and stent use.

Back to Top | Article Outline

Anxiety

Anxiety was measured by HADS. This instrument was chosen because it is short, easy to use and interpret, translated to Arabic, valid, and reliable.32–36 In the Arabic version, the overall Cronbach’s α measure of internal consistency for the anxiety subscale was .78.34 The sensitivity and specificity of the anxiety subscale were high at 86% and 87%, respectively.34–36 The HADS is a 7-item questionnaire in which the participants rated each item on a scale of 0 to 3, with 3 indicating higher symptom frequency and severity. The total score can range from 0 to 21, with higher scores indicating higher levels of anxiety. The scores are categorized as follows: 0 to 7, normal; 8 to 10, mild; 11 to 14, moderate; and 15 to 21, severe.32 anxiety.

Back to Top | Article Outline

In-hospital Complications

Complications were defined as in our previous studies5,7,11 as the occurrence of any of the following during hospitalization: (a) reinfarction evidenced by elevated cardiac enzymes and standard ECG changes; (b) supraventricular tachyarrhythmia with hemodynamic instability, (c) acute recurrent ischemia evidenced by new onset of chest pain, with ECG changes or hemodynamic instability; (d) sustained ventricular tachycardia (>15 seconds) or any ventricular tachycardia requiring pharmacological and/or electrical intervention; (e) ventricular fibrillation; (f) cardiogenic shock; (g) acute pulmonary edema; or (h) in-hospital death. In addition, we measured intensive care unit (ICU) and hospital lengths of stay (LOSs) from the medical record.

Back to Top | Article Outline

Data Analysis

SPSS software version 20.0 was used to analyze the data (SPSS Inc, Chicago, Illinois). P < .05 was considered significant. Descriptive statistics with frequencies and percentages or mean (SD) were used to describe the sociodemographic and clinical characteristics of the sample based on gender. The first 2 hypotheses of the study were tested by independent-sample t test. Correlations between anxiety scores for both genders and the total number of complications, ICU LOS, and hospital LOS were examined using the Pearson r correlation coefficient. Predictors of number of complication for both genders were tested using logistic regression.

Back to Top | Article Outline

Results

A total of 250 patients participated in this study, 163 men and 87 women. Sociodemographic and clinical characteristics of the sample, by gender, are presented in Table 1. Approximately three-quarters of the sample was hypertensive, more than half of the sample had previous AMI, and most of them had a history of angina. Male patients more often had diabetes (χ2 = 4.47, P < .05), had a higher prevalence of previous AMI (χ2 = 10.81, P < .01), and had coronary artery bypass graft surgery more commonly (χ2 = 8.84, P < .01) than female patients did.

TABLE 1

TABLE 1

More than a third of the sample (38.4%) developed 1 or more complications during hospitalization (Table 2). A total of 41.4% of women and 36.4% of men developed complications. Female patients were significantly more anxious and had more complications than male patients did (Table 3). Female patients were severely anxious based on the HADS criteria with a mean (SD) for the HADS of 15.5 (3.6). Male patients were mildly anxious based on a mean (SD) for the HADS of 8.1 (2.9).

TABLE 2

TABLE 2

TABLE 3

TABLE 3

The correlation between anxiety scores for both genders and the total number of complications, ICU LOS, and hospital LOS were examined (Table 4). There was a strong positive significant correlation between anxiety scores for male patients and number of complications (r = 0.65, P < .001). With regard to female patients, there was also a strong positive significant correlation between their anxiety scores and number of complications (r = 0.77, P < .001). In addition, there was a positive significant correlation between anxiety scores for female patients with LOS in the ICU and LOS in the hospital (r = 0.43, P < .05; r = 0.44, P < .001, respectively).

TABLE 4

TABLE 4

Predictors of number of complications were determined using logistic regression with the same predictors entered in separate equations for male and female patients. Previous AMI and anxiety scores were independent predictors of complication for female patients (Table 5), whereas anxiety scores were the only predictor for complication of male patients (Table 6). The odds ratio from predictors of number of complications from anxiety in women was 1.31, whereas the odds ratio for men was 1.20.

TABLE 5

TABLE 5

TABLE 6

TABLE 6

Back to Top | Article Outline

Discussion

This was the first study specifically designed to examine differences in anxiety levels and complication rate after AMI between genders in a developing country. The major findings of this study were that women have higher levels of anxiety and post-AMI complications than men do. In addition, women’s levels of anxiety were severe compared with the milder levels seen in men.

Almost all previous studies on gender differences in anxiety after AMI23–27,37,38 were conducted in developed countries. This study was conducted in a developing country to replicate or refute findings from developed countries. The results of the current study are quite similar to those in developed countries, suggesting that anxiety has the same effects on complications after AMI in both genders and that anxiety levels are higher in women across a wide variety of cultures.

The mean anxiety level of all patients in the sample was higher than that of healthy people—a finding of concern given the association of anxiety with poor outcomes in cardiac patients. Anxiety in cardiac patients is associated independently with higher short- and long-term morbidity and mortality.39 Anxiety predicted future coronary events and long-term survival after AMI.40 Anxiety has been shown to negatively affect quality of life and persists months to years after AMI.41

Previous studies5,11 have shown that anxious patients were at a higher risk for in-hospital complications and stayed longer in the hospital and in the ICUs than nonanxious patients did. In this study, anxiety was an independent predictor of complications after controlling for sociodemographic and clinical variables for both genders supporting results of previous studies. This also might explain why women had higher complication rates than men did.

Increased anxiety after AMI has been recognized by others for decades and continues to be a concern.42,43 However, comparison of results among different countries is limited, despite potential differences in the incidence and expression of anxiety across countries. For example, in Jordan, extended family systems are common and provide support for patients to help them work through their stress and anxiety, especially in critical situations.44 Despite the presence of this support, in this study, male and female patients experienced high levels of anxiety as did other patients in other countries. The findings of this study suggest that, despite the potential effect of culture on emotions,45,46 patients with AMI from many different countries exhibit similar emotional responses to this potentially life-threatening event.

These results are consistent with another study6 conducted to evaluate whether anxiety after AMI differed across 5 unlike countries and to determine whether an interaction between country and sociodemographic and clinical variables contributed to variations in reporting anxiety. All patients in all countries had higher levels of anxiety than did healthy people, and culture itself did not account for variation in the anxiety. The authors concluded that anxiety is a global health problem.

Back to Top | Article Outline

Summary and Conclusions

Jordanian women are more anxious and have more complications after AMI than men do, although both have high levels and anxiety is associated with post-AMI complications. This result is similar with those from developed countries, suggesting that anxiety is a global health problem after AMI. A successful area for future research includes exploration of reasons why women representing different cultures are at a higher risk for anxiety after AMI than men are. Intervention studies are needed to address this anxiety.

Back to Top | Article Outline

What’s New and Important

  • This is the first study designed specifically to check gender differences in the anxiety levels after AMI in a developing country.
  • Anxiety is a global health problem after AMI. Almost all previous studies were conducted in the United States, Europe, and far east countries, and none was conducted in the middle east.
  • Women in the middle east with AMI have higher levels of anxiety and higher complication rates compared with men.
Back to Top | Article Outline

Acknowledgment

The author is grateful to the Applied Science Private University, Amman, Jordan, for the partial financial support granted to this research project and the financial support granted to cover the publication fees of this research article.

Back to Top | Article Outline

REFERENCES

1. Moser DK. “The rust of life”: impact of anxiety on cardiac patients. Am J Crit Care. 2007;16(4):361–369.
2. Mozaffarian D, Benjamin EJ, Go AS, et al. Heart disease and stroke statistics—2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29–e322.
3. Gehani AA, Al-Hinai AT, Zubaid M, et al. Association of risk factors with acute myocardial infarction in Middle Eastern countries: the INTERHEART Middle East study. Eur J Prev Cardiol. 2014;21(4):400–410.
4. WHO. Jordan: WHO statistical profile. Country statistics and global health estimates by WHO and UN partner. 2015. http://www.who.int/countries/jor/en/. Accessed October 5, 2016.
5. Abu Ruz ME, Lennie TA, Moser DK. Effects of beta-blockers and anxiety on complication rates after acute myocardial infarction. Am J Crit Care. 2011;20(1):67–73.
6. De Jong MJ, Chung ML, Roser LP, et al. A five-country comparison of anxiety early after acute myocardial infarction. Eur J Cardiovasc Nurs. 2004;3(2):129–134.
7. McKinley S, Fien M, Riegel B, et al. Complications after acute coronary syndrome are reduced by perceived control of cardiac illness. J Adv Nurs. 2012;68(10):2320–2330.
8. Hanssen TA, Nordrehaug JE, Eide GE, Bjelland I, Rokne B. Anxiety and depression after acute myocardial infarction: an 18-month follow-up study with repeated measures and comparison with a reference population. Eur J Cardiovasc Prev Rehabil. 2009;16(6):651–659.
9. Wrenn KC, Mostofsky E, Tofler GH, Muller JE, Mittleman MA. Anxiety, anger, and mortality risk among survivors of myocardial infarction. Am J Med. 2013;126(12):1107–1113.
10. Roest AM, Martens EJ, Denollet J, de Jonge P. Prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. Psychosom Med. 2010;72(6):563–569.
11. Aburuz M, Saifan A, Demeh W. Anxiolytic medication use does not have a protective effect against complications after acute myocardial infarction. Life Sci J. 2013;10(4):1333–1337.
12. Abed MA, Frazier S, Hall LA, Moser DK. Anxiolytic medication use is not associated with anxiety level and does not reduce complications after acute myocardial infarction. J Clin Nurs. 2013;22(11–12):1559–1568.
13. Moser DK, Dracup K. Is anxiety early after myocardial infarction associated with subsequent ischemic and arrhythmic events? Psychosom Med. 1996;58(5):395–401.
14. Moser DK, Riegel B, McKinley S, Doering LV, An K, Sheahan S. Impact of anxiety and perceived control on in-hospital complications after acute myocardial infarction. Psychosom Med. 2007;69(1):10–16.
15. Frasure-Smith N, Lesperance F. Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiatry. 2008;65(1):62–71.
16. Frasure-Smith N, Lesperance F, Talajic M. The impact of negative emotions on prognosis following myocardial infarction: is it more than depression? Health Psychol. 1995;14(5):388–398.
17. Benninghoven D, Kaduk A, Wiegand U, Specht T, Kunzendorf S, Jantschek G. Influence of anxiety on the course of heart disease after acute myocardial infarction—risk factor or protective function? Psychother Psychosom. 2006;75(1):56–61.
18. Nakamura S, Kato K, Yoshida A, et al. Prognostic value of depression, anxiety, and anger in hospitalized cardiovascular disease patients for predicting adverse cardiac outcomes. Am J Cardiol. 2013;111(10):1432–1436.
19. Mayou RA, Gill D, Thompson DR, et al. Depression and anxiety as predictors of outcome after myocardial infarction. Psychosom Med. 2000;62(2):212–219.
20. Welin C, Lappas G, Wilhelmsen L. Independent importance of psychosocial factors for prognosis after myocardial infarction. J Intern Med. 2000;247(6):629–639.
21. Lane D, Carroll D, Ring C, Beevers DG, Lip GY. Effects of depression and anxiety on mortality and quality-of-life 4 months after myocardial infarction. J Psychosom Res. 2000;49(4):229–238.
22. Herrmann C, Brand-Driehorst S, Buss U, Rüger U. Effects of anxiety and depression on 5-year mortality in 5,057 patients referred for exercise testing. J Psychosom Res. 2000;48(4–5):455–462.
23. An K, De Jong MJ, Riegel BJ, et al. A cross-sectional examination of changes in anxiety early after acute myocardial infarction. Heart Lung. 2004;33(2):75–82.
24. Moser DK, Dracup K, McKinley S, et al. An international perspective on gender differences in anxiety early after acute myocardial infarction. Psychosom Med. 2003;65(4):511–516.
25. Carmin CN, Ownby RL, Wiegartz PD, Kondos GT. Women and non-cardiac chest pain: gender differences in symptom presentation. Arch Womens Ment Health. 2008;11(4):287–293.
26. Bosner S, Haasenritter J, Hani MA, et al. Gender differences in presentation and diagnosis of chest pain in primary care. BMC Fam Pract. 2009;10:79.
27. Kim KA, Moser DK, Garvin BJ, et al. Differences between men and women in anxiety early after acute myocardial infarction. Am J Crit Care. 2000;9(4):245–253.
28. Crowe JM, Runions J, Ebbesen LS, Oldridge NB, Streiner DL. Anxiety and depression after acute myocardial infarction. Heart Lung. 1996;25(2):98–107.
29. Rose SK, Conn VS, Rodeman BJ. Anxiety and self-care following myocardial infarction. Issues Ment Health Nurs. 1994;15(4):433–444.
30. Webb MS, Riggin OZ. A comparison of anxiety levels of female and male patients with myocardial infarction. Crit Care Nurse. 1994;14(1):118–124.
31. Cohen J. A power primer. Psychol Bull. 1992;112(1):155–159.
32. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the Hospital Anxiety and Depression Scale. An updated literature review. J Psychosom Res. 2002;52(2):69–77.
33. el-Rufaie OE, Absood G. Validity study of the Hospital Anxiety and Depression Scale among a group of Saudi patients. Br J Psychiatry. 1987;151:687–678.
34. el-Rufaie OE, Absood GH. Retesting the validity of the Arabic version of the Hospital Anxiety and Depression (HAD) scale in primary health care. Soc Psychiatry Psychiatr Epidemiol. 1995;30(1):26–31.
35. el-Rufaie OE, Albar AA, Al-Dabal BK. Identifying anxiety and depressive disorders among primary care patients: a pilot study. Acta Psychiatr Scand. 1988;77(3):280–282.
36. Malasi TH, Mirza IA, el-Islam MF. Validation of the Hospital Anxiety and Depression Scale in Arab patients. Acta Psychiatr Scand. 1991;84(4):323–326.
37. Ladwig KH, Mühlberger KH, Walter H, et al. Gender differences in emotional disability and negative health perception in cardiac patients 6 months after stent implantation. J Psychosom Res. 2000;48(4–5):501–508.
38. Westin L, Carlsson R, Erhardt L, Cantor-Graae E, McNeil T. Differences in quality of life in men and women with ischemic heart disease: a prospective controlled study. Scand Cardiovasc J. 1999;33(3):160–165.
39. Lane D, Carroll D, Ring C, Beevers DG, Lip GY. Mortality and quality of life 12 months after myocardial infarction: effects of depression and anxiety. Psychosom Med. 2001;63(2):221–230.
40. Denollet J, Brutsaert DL. Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction. Circulation. 1998;97(2):167–173.
41. Brenes GA. Anxiety, depression, and quality of life in primary care patients. Prim Care Companion J Clin Psychiatry. 2007;9(6):437–443.
42. Frasure-Smith N, Lespérance F, Prince RH, et al. Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction. Lancet. 1997;350(9076):473–479.
43. Januzzi JL Jr, Stern TA, Pasternak RC, DeSanctis RW. The influence of anxiety and depression on outcomes of patients with coronary artery disease. Arch Intern Med. 2000;160(13):1913–1921.
44. Masa’Deh R, Saifan A, Timmons S, Naim S. Families’ stressors and needs at time of cardio-pulmonary resuscitation: a Jordanian perspective. Global J Health Sci. 2013;6(2):72.
45. Kirmayer LJ. Cultural variations in the clinical presentation of depression and anxiety: implications for diagnosis and treatment. J Clin Psychiatry. 2001;62(suppl 13):22–28.
46. Draguns JG, Tanaka-Matsumi J. Assessment of psychopathology across and within cultures: issues and findings. Behav Res Ther. 2003;41(7):755–776.
Keywords:

acute myocardial infarction; anxiety; complications; gender

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved