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Psychological distress can have an important influence on the physical and psychological health of cardiac patients following surgery, highlighting the merits of pre-surgery education and attending cardiac rehabilitation programs.
Cardiovascular disease (CVD) is the leading cause of death in Australia and around the world, responsible for 24% of all deaths in Australia in 2022. It is estimated that 12% to 20% of Australians aged between 47 and 74 years have a high risk of developing CVD. There were 600 000 hospitalisations from 2021 to 2022 due to CVD, with many of these cases requiring open-heart surgery. Thankfully, the mortality of CVD among Australians has decreased substantially over several decades from 830 deaths per 100 000 people (1968) to 173 deaths per 100 000 people (2022).
A common surgical intervention for CVD involves open-heart surgery, specifically coronary artery bypass graft surgery. Recovery from cardiac surgery can be long and arduous, and the existing evidence suggests that the most pressing health concern for cardiac patients following surgery is psychological distress, defined here as elevated anxiety, depression and stress.
Even before cardiac surgery, patient distress is often elevated, with 30% to 40% of patients meeting cut-offs for clinical psychological diagnoses. Following coronary artery bypass graft surgery, up to 10% of patients experience generalised anxiety disorder, and up to 50% experience depression — either having depressive symptoms or major depressive disorder. These symptoms have been observed to persist for over a year and negatively affect a patient’s recovery in a variety of ways.
Compared with non-distressed patients, distressed patients have a 130% to 181% increased likelihood of future coronary disease incidents (eg, hospitalisation), and 122% increased rate of combined cardiac mortality and cardiac attacks.
Our recent review evaluates and synthesises studies of patients with CVD to identify the role of personal (eg, age and gender), social (eg, social support), and health service (eg, cardiac rehabilitation) factors that may influence distress after surgery.
What we found
Age and sex
There were varied findings about whether age and sex predicted patient distress and cardiac outcomes. Older patients appear to be more resilient to distress, though they also had less access and variety of social resources that can aid in reducing distress. Compared with men, women more commonly reported greater discomfort, long term pain, and greater general disposition to distress; however, women are commonly more willing to report these experiences than men.
Post-surgical pain
Physical pain and distress appear to influence each other reciprocally. Specifically, increased pain is associated with increased distress after surgery and vice versa.
Physical activity
Patients who were physically active before surgery reported less distress after surgery. Likewise, patients performing physical activity following surgery also had less distress. A lack of activity is associated with two to three times greater rates of depression. Interestingly, increased physical activity after surgery was most beneficial for patients who experienced high distress after surgery compared with those with high distress before surgery.
Social relationships
Better quality of life and less distress were reported among patients who were regularly involved in social groups, not living alone, and had greater social support. Patients with partners and close social support (eg, family, carers and partners) reported lower distress after surgery. However, 11% of cardiac patients live alone and do not have this social protective factor.
Pre-operative education
Pre-operative education appears to influence patients’ recovery in several important ways. The majority of evidence suggests attending pre-operative education is associated with decreased patient distress immediately after surgery and for up to one year later.
Cardiac rehabilitation
Participation in cardiac rehabilitation programs reliably produce reductions in distress after surgery. Greater improvements were also noted when patients were satisfied with the quality of rehabilitation. Group-led sessions, information quality, and psychological treatment were especially important elements of the program. However, only 20% to 40% of eligible patients attend cardiac rehabilitation programs and this number is even lower for rural and remote patients.
Recommendations for clinical practice
There are several clinical implications for hospitals and medical professionals.
- Both hospital and medical professionals should consider whether patients have family support before discharging them. If this support is not available, hospitals should consider encouraging patients to engage with local social support groups (eg, Heart Foundation social forums, Rotary clubs, social events etc).
- Cardiac patients would benefit from attending both pre-operative education and cardiac rehabilitation. Health professionals should provide greater emphasis on the importance of long term patient health (including decreased risk of future cardiac events).
- High pre-operative distress predicts post-operative distress; therefore, patients should be screened upon hospital admission and provided with additional psychosocial support if they have elevated distress levels.
- Health professionals should carefully monitor pain in patients before and after discharge, as increased levels predict distress. If patients are in pain, psychosocial support in addition to medical support should be provided to them.
- Patients should be encouraged not to live a sedentary lifestyle and be educated on the benefit of consistent physical exercise before and after surgery. This does not mean patients have to run marathons, but rather be conscious of maintaining regular physical activity.
Participation in pre-operative education appears to be the strongest predictor of decreased distress, with strong evidence that close family and partner relationships are also a critical protective factor. Importantly, there are opportunities for not only health practitioners but the whole health ecosystem to actively support patients and reduce their distress throughout their surgical journey.
William D McCann is a PhD student in Psychology at the University of Southern Queensland.
Xiang-Yu Hou is a Principal Research Fellow, an Associate Professor at Poche Centre for Indigenous Health, The University of Queensland.
Snezana Stolic is a Senior Lecturer of Nursing at the University of Southern Queensland, with 24 years of clinical experience in cardiac nursing.
Michael J Ireland is a research scientist and Associate Professor of Psychology at the University of Southern Queensland.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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