Social Support and Adjustment to Myocardial Infarction, Angioplasty, and Coronary Artery Bypass Surgery

Overview

In this chapter we examine social support during three acute cardiac events: myocardial infarction (MI), angioplasty, and coronary artery bypass graft (CABG) surgery. The first event, MI, is life threatening and is characterized by sudden onset as a result of coronary artery thrombosis. Patients are commonly hospitalized for 7 to 10 days, and recovery periods (including participation in cardiac rehabilitation programs) can range up to 6 weeks or longer. Close to one half of the 1.3 million persons experiencing MI each year survive to leave the hospital (Garrity, 1981). Of these, approximately 10% will die during the following year. Subsequently, nonfatal reinfarctions occur at an average annual rate of 3%, and coronary artery disease deaths occur at a rate of 5%, three to four times higher than that of the general population (Kannel, Sorlie, & McNamara, 1979). Myocardial impairment and severity of the underlying disease are the strongest predictors of early mortality (Henning et al., 1979; Sanz, Castaner, Betriu, & Magria, 1982). Three to five percent of patients will undergo CABG surgery within 3 months following an MI (Davidson, 1983).

CABG surgery is a procedure involving the creation of a saphenous vein or mammary artery “bypass” to allow blood to flow around the narrowed or blocked portion of a coronary artery. Patients are hospitalized for about 6 to 7 days, and recovery periods can range up to 6 months. It is estimated that more than 1 million patients have undergone this procedure since its development (Davidson, 1985), and more than 250,000 surgeries are performed yearly in the United States (Politser & Cunico, 1988); approximately 45% of these involve three or more grafts (National Heart, Lung, and Blood Institute [NHLBI], 1988). The number of bypasses performed on a given patient generally ranges from two to five per patient, and approximately 5% to 10% of surgeries are reoperations (Davidson, 1983). For patients with more extensive or specific forms of coronary artery disease (i.e., main artery disease or three-vessel disease), surgery has been shown to prolong life (Hall et al., 1983; NHLBI, 1988). This outcome, however, has not been demonstrated for the majority of patients having undergone the procedure (Detre et al., 1985; Murray & Beller, 1983). Some groups (e.g., patients with stable ischemic heart disease) are no longer viewed as candidates for CABG unless symptoms worsen (CASS Principal Investigators, 1983a). Symptomatic improvement occurs in 70% to 80% of CABG patients (Davidson, 1985; NHLBI, 1988), although 10% to 20% experience a recurrence of symptoms (Murray & Beller, 1983).

Percutaneous transluminal coronary angioplasty (PTCA) is a procedure performed in the cardiac catheterization laboratory with a cardiac surgery team standing by in case an emergency CABG surgery is required. Indicators for the procedure are generally chest pain and angioplasty with blockage or prior MI. It is estimated that 5% to 10% of patients who are candidates for coronary bypass surgery meet recommended selection criteria for having PTCA as an adjustment treatment (Greenspon & Goldberg, 1983). Furthermore, a small proportion of PTCA patients go on to have emergency or elective CABG because the procedure is not successful (Greenspon & Goldberg, 1983). During PTCA, a catheter is introduced into the coronary arteries via an artery in the arm or groin. A second, smaller catheter with a balloon at the end of it is passed through the first one. The balloon tip is then inflated, compressing the atherosclerotic plaque and dilating the soft inner wall of the artery. The procedure widens the coronary artery and thereby increases blood flow to the heart. Patients are usually discharged within 2 days or less and frequently return to normal activities within 1 week following the procedure; however, 20% to 30% of patients require the procedure again within 6 months (Jutzy, Berte, Alderman, Ratts, & Simpson, 1982; Kent et al., 1982). In 1983, 20,000 PTCAs were performed in the United States and predictions estimate that in 1987, this number will have increased to 140,000 (American Heart Association, 1986).

Early results were encouraging as to the value of PTCA in preventing coronary events in selected patients (P. Block, 1985). Comparison of PTCA and CABG outcomes for patients matched demographically and by cardiac condition showed the PTCA group was functioning significantly better 6 and 15 months posttreatment (Raft, McKee, Popio, & Haggerty, 1985). Results from the TIMI-II tria) in Boston, however, indicate that MI patients do not need angioplasty if they quickly receive clot-dissolving medications.

A common issue for all three of these patient groups (MI, CABG, PTCA) is their underlying coronary artery disease and the physical, psychological, and social implications of that diagnosis (Davidson, 1983; Doehrman, 1977; Garrity, 1981). Each of these patient groups is aware that their heart is the object of concern, a body organ with considerable symbolic meaning (Goldman & Kimball, 1985; Carr & Powers, 1986). Patients are faced with the threat of both symbolic and actual losses ranging from loss of affection to loss of life. Moreover, patients commonly experience pain in the form of postsurgical discomfort and occasionally angina, significant physical deconditioning from forced inactivity, extended rehabilitation, further treatment decisions, and the threat of recurrence resulting from the ongoing disease process. In the case of CABG or PTCA, many patients have experienced increasing disability over an extended period of time prior to treatment and therefore may experience severe disappointment if blockage or narrowing of the artery occurs again (restenosis) or if angina or chest pain occur following initial treatment (Shaw et al., 1986). Despite many commonalities, however, these three types of cardiac patients each experience distinct events and reactions.

Substantial data indicate that the social and psychological contexts surrounding these acute cardiac episodes influence cardiac outcomes and the overall quality of life of patients and their families (Case, Moss, Case, McDermott & Eberly, 1992; Fletcher, Hunt & Bulpitt, 1987; Folks, Blake, Fleece, Sokol & Freeman, 1986; LaMendola & Pellegrini, 1979; Lloyd & Cawley, 1983; Ruberman, Weinblatt, Goldberg & Chaudhary, 1984; Waltz, 1986b; Williams et al., 1992). Furthermore, social support from both primary network members and professional caregivers is assumed to be an important resource in patients’ perceptions of their experiences and in the coping strategies they employ to adapt to the changing life circumstances that result from the event (Caplan, 1976; Dean & Tausing, 1986).

In this chapter we examine the effects of social support as they may influence the patients’ recognition of symptoms and their health care-seeking behavior, treatment decision making, hospitalization, and early psychosocial adaptation (approximately 2 to 3 months postdischarge). The experience of the patients’ families will be examined in terms of their roles as both support providers to the cardiac patient and recipients of professional caregiver support. Supportive care by health care practitioners will be considered primarily through a review of extant intervention research. Finally, we set a future research agenda.