A MIXED METHODS STUDY INVESTIGATING RE-PRESENTATION, SYMPTOM ATTRIBUTION and PSYCHOLOGICAL HEALTH IN PRIMARY PERCUTANEOUS CORONARY INTERVENTION PATIENTS

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Abstract

Introduction: Following ST-elevation myocardial infarction (STEMI) and treatment with Primary Percutaneous Coronary Intervention (PPCI), some patients re-present with potential ischaemic heart disease (IHD) symptoms. Symptoms may be related to cardiac ischaemia, reduced psychological health or a comorbid condition, which share similar symptoms and may lead patients to seek help via acute services. The purpose of the study was to investigate the proportion of PPCI patients who re-presented to acute services due to potential IHD symptoms within 6 months of STEMI, and to explore associated factors.Methods: An explanatory mixed methods study was conducted. Quantitative data were collected at baseline and 6 months from consecutive patients attending two centres in Manchester. Variables were carefully considered based on a conceptual model for re-presentation. These included potential IHD symptom and psychological health assessments using self-report measures: the Seattle Angina Questionnaire (SAQ) and the Hospital and Anxiety and Depression Scale (HADS). Physiological health was measured using the Global Registry of Acute Coronary Events (GRACE) and the Charleson Comorbidity Index (CCI) at baseline. At 6 months re-presentation data were collected using patient records, a telephone interview and a self-report diary card. The experiences of some who re-presented (purposeful sampling) were explored through semi-structured interviews conducted at least 6 months following PPCI. Framework analysis was adopted to analyse data.Results: 202 PPCI patients returned baseline questionnaires [mean age 59.7 years (SD 13.9), 75.7% male]; 38 (18.8%; 95% CI 14.0% to 24.8%) participants re-presented due to potential IHD symptoms at 6 months; 16 (42.1%) re-presented due to a cardiac event and 22 (57.9%) did not receive a diagnosis. At both baseline and 6 months, mean HADS anxiety scores were higher for the re-presentation group compared to the non-representation group (baseline 9.5 vs 7.1, p=0.006; 6 months 9.4 vs 6.0, p<0.001). Angina symptoms were stable and infrequent at both time points for the groups. Multivariate regression modelling with the inclusion of predictors HADS anxiety, SAQ angina stability, SAQ angina frequency, GRACE and CCI, determined HADS anxiety as a predictor of re-presentation with an adjusted odds ratio of 1.12 (95% CI 1.03 to 1.22, p=0.008). The qualitative interviews with re-presenters included 25 participants (14 men, 27-79 years). Four themes were identified: fear of experiencing a further heart attack, uncertainty and inability to determine cause of symptoms, insufficient opportunity to validate self-construction of illness and difficulty adapting to life after a heart attack.Conclusion: Elevated levels of anxiety at baseline were predictive of re-presentation with potential IHD symptoms at 6 months. Factors such as shock at experiencing a heart attack, hypervigilance of symptoms and difficulty with symptom attribution appeared to play a role in raised anxiety levels for the re-presentation group. Findings suggested that changes are needed to cardiac rehabilitation and post-STEMI follow-up to address educational needs and psychological issues and changes in STEMI treatment.

Keyword(s)

Anxiety and Depression; Primary Percutaneous Coronary Intervention; Re-presentation; ST-elevation myocardial infarction; Symptoms

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