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Illness Representation After Acute Myocardial Infarction: Impact On In-Hospital Recovery

	Abstract

Top Abstract Self-Regulation Model of Illness Background Methods Results Discussion Recommendations for Future... Conclusion References

 
• Background Despite significant progress in the treatment of coronary artery disease, myocardial infarction is still the leading cause of death in the United States. As suggested by Leventhal’s Self-Regulation Model of Illness, the continued high morbidity and mortality may be due to a failure to address the role of psychosocial factors such as illness representation, depression, and anxiety in recovery.

• Objective To determine the relationship between illness representation of myocardial infarction and the occurrence of in-hospital complications and if anxiety and depression mediate this relationship.

• Method A prospective correlational design was used to measure illness representation, depression, and anxiety 24 to 48 hours after admission for myocardial infarction in 49 patients and the frequency of complications during the acute event. Logistic regression was used to determine the likelihood of experiencing a complication.

• Results When demographic and clinical variables were controlled for, the more negative the representation of illness, the greater were the odds of experiencing a complication (² = 16.9, df = 6, P=.01). The odds of experiencing a complication increased 5.1% for each 1 unit increase in the score on the Illness Preparation Questionnaire (B = 0.05, Wald = 4.442, Exp(B) = 1.051, 95% CI = 1.003–1.1010). Neither anxiety (² = 3.0, df = 1, P = .09) nor depression (² = 2.5, df = 1, P = .11) were significant predictors of the occurrence of complications.

• Conclusion In these patients, illness representation was predictive of the likelihood of experiencing a complication. Thus, illness representation appears to be an important psychosocial factor in acute recovery from myocardial infarction.

To receive CE credit for this article, visit the American Association of Critical-Care Nurses’ (AACN) Web site at http://www.aacn.org, click on "Education" and select "Continuing Education," or call AACN’s Fax on Demand at (800) 222-6329 and request item No. 1175.

One reason for the continued high morbidity and mortality may be failure to address the role of psychosocial factors in recovery from myocardial infarction. A number of psychosocial factors such as depression and anxiety influence recovery from myocardial infarction independently of traditional risk factors.^3–5 What remains unclear is the role of other psychosocial factors. Further examination of the interaction of physical and psychosocial factors related to morbidity after myocardial infarction is needed to identify risk factors for poorer recovery from and adaptation to myocardial infarction. Identification of the mediating psychosocial and physical factors that precede poorer recovery will allow the development of interventions to decrease morbidity and, possibly, mortality after myocardial infarction. Research suggests that illness representation is such a factor.⁶

	Self-Regulation Model of Illness

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According to the self-regulation model of illness (SRMI, see Figure), when persons face a health threat such as myocardial infarction, they form a representation of the illness.⁷ Internal and external variables, including health history, personality, social environment, and demographic factors, contribute to illness representation. Together with the health threat, these factors influence the perception of the identity, cause, cure/controllability, time line, and consequences of the illness being experienced. A person who has a positive illness representation accurately identifies signs and symptoms and the cause of the disease and thinks that the problem is curable or controllable, that the course of the disease is intermittent, and that the level of disability or seriousness of the disease is low⁸ (E. F. Buick and K. J. Petrie, unpublished data).

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	Background

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In contrast, the various attributes of illness representation have been examined in numerous studies. The results of several studies support the formation of representations of illness after myocardial infarction. In most of the studies, only 1 or 2 of the attributes of illness representation were measured. Findings included the following: Patients with hypertension, diabetes, or family history of CAD did not identify these factors as a possible cause of their CAD.¹¹ Patients who engaged in causal search (seeking to understand the cause of myocardial infarction) were more anxious than were those who did not.¹² Attributing the cause of myocardial infarction to the stress response was predictive of mortality 7 to 8 years after the infarction.¹³ Attributing the cause of myocardial infarction to personal behavior, other persons, the stress response, and heredity also was related to reinfarction 7 to 8 years after the original infarction.¹⁴

After a health threat, a personal and unique representation of illness is formed.

 

Regaining control was the core process in adjustment after myocardial infarction.¹⁵ When sociodemographic and clinical variables were controlled for, only perceived control contributed significantly to explaining differences in recovery.¹⁶ Most patients (63%) who had CAD perceived their illness as a chronic, long-term problem.¹¹ In a study by Bennett,¹⁷ the consequences (measured as threat) along with marital status, availability of social support, time since the acute event, uncertainty, coping strategies, and emotions explained 63% of the variance in coping effectiveness after myocardial infarction. Patients with myocardial infarction whose signs and symptoms were more disruptive took them more seriously and were quicker to identify them as a health threat than were patients with less disruptive manifestations.¹⁸ In one study, investigators¹⁹ found a significant positive relationship between a more serious perception of illness and rehospitalization and mortality 1 year after myocardial infarction.

The lack of measurement of all the attributes limits the ability to assess the impact of the meaning and significance of experiencing a myocardial infarction. A second limitation of the published findings was the paucity of studies in which investigators examined the relationship between the attributes and outcomes after myocardial infarction. Understanding the correlation between the meaning and importance of illness and outcomes is needed to determine if interventions should be tested to alter the impact of illness representation on recovery. On the basis of the SRMI, one could hypothesize that patients with myocardial infarction who have a negative perception of their illness are more likely to have a complicated recovery than are patients with a more positive perception of their illness.^6,7

The purpose of this study was to determine the relationship between illness representation at the time of myocardial infarction and the occurrence of in-hospital complications and to determine whether anxiety and depression mediate this relationship. We tested 3 hypotheses:

1. When age, sex, socioeconomic status, and clinical variables are controlled for, the more negative the representation of illness, the more likely is the occurrence of complications.
   
2. When age, sex, socioeconomic status, and clinical variables are controlled for, an interaction occurs between negative illness representation and anxiety that increases the likelihood of complications during hospitalization.
   
3. When age, sex, socioeconomic status, and clinical variables are controlled for, an interaction occurs between negative illness representation and depression that increases the likelihood of complications during hospitalization.
   

	Methods

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A prospective predictive correlational design was used to measure illness representation, depression, and anxiety at the time of myocardial infarction and the occurrence of complications during the acute hospital stay. Initial data were collected 24 to 48 hours after admission. After patients were discharged, their medical records were reviewed for the occurrence of complications.

Subjects and Setting
Data were collected in a 32-bed coronary care unit of Riverside Methodist Hospital in Columbus, Ohio. Potential subjects included all patients with a confirmed diagnosis of myocardial infarction who could read and write English, were 18 years or older, had stable vital signs (at the time of the interview), were pain-free, had been treated with coronary revascularization by percutaneous transluminal coronary angioplasty, and were receiving a ß-adrenergic blocking agent. Diagnosis of myocardial infarction was confirmed by using the World Health Organization criteria of the presence of 2 of the following: chest pain lasting longer than 30 minutes, ST-segment elevation greater than 1 mm in 2 contiguous leads, and elevated serum level of creatine kinase–MB or troponin T. Eligibility was limited to patients treated with percutaneous transluminal coronary angioplasty in order to eliminate differences in treatment as a confounding variable. Potential subjects who had a history of coronary artery bypass graft surgery or who were treated with coronary artery bypass grafting were excluded because their recovery process differed from that of patients who had angioplasty. Potential subjects who were not receiving a ß-adrenergic blocking agent were excluded because of the importance of the blocking agents in the prevention of complications related to myocardial infarction. Ventricular dysrhythmias would be more likely in patients not receiving a ß-adrenergic blocker than in patients treated with such a blocking agent.²⁰

Procedure
Approval for the study was obtained from the institutional review boards of the appropriate institutions. The charge nurse in the coronary care unit referred patients who had a diagnosis of myocardial infarction or who were admitted for studies to rule out myocardial infarction or chest pain to the principal investigator or research assistant. The study was explained to eligible patients, and written informed consent was obtained from those who decided to participate in the investigation.

Patients were interviewed to obtain sociodemographic data and health history and were given a questionnaire packet. Participants were compensated in the amount of US $10 at the end of the data collection. After patients were discharged, their medical records were reviewed to determine the number and type of complications.

For each patient, all data except the occurrence of complications were collected while he or she was an inpatient. The investigator read the items to the patients so that possible fatigue and/or distress could be observed. The order in which the instruments were presented was rotated to control for testing effects of administering multiple instruments.²¹ All data were collected by 1 of 2 advanced practice nurses with many years of experience in cardiac critical care.

Instruments
Illness representation was measured by using the Illness Perception Questionnaire (IPQ)²²; anxiety, by using the Spielberger State Anxiety Inventory (SSAI)²³; and depression, by using the second edition of the Beck Depression Inventory (BDI).²⁴ The occurrence of complications was assessed as the number of complications that occurred within the hospital stay.

  Illness Perception Questionnaire.   The IPQ was used to measure illness representation. The questionnaire was developed to assess the cognitive representations of illness as described by Leventhal. The instrument consists of 5 scales, 1 scale for each of the 5 concepts of illness representation: identity, cause, cure/controllability, time line, and consequences.⁶ Identity was measured by using a list of 15 symptoms such as chest pain, nausea, and fatigue for which patients were asked to note if they had experienced the symptom during the heart attack and if they thought the symptom was related to their heart condition. Scores on this scale range from 0 to 15. A higher score indicates a greater number of symptoms associated with the heart attack.

Time line, controllability/cure, and consequences were measured by using a 29-item Likert scale. Response choices range from strongly disagree to strongly agree. Higher scores on the time-line scale (9 items) indicate the belief that illness will last a long time. High scores on the cure/control scale (10 items) indicate the belief that the illness can be controlled or cured. Higher scores on the consequence scale (9 items) indicate the perception of serious consequences related to having a heart attack.^10,22

Cause was measured by using a 16-item Likert 5-point scale; possible responses range from strongly disagree to strongly agree. Patients were instructed to rate their level of agreement with each item as a cause of their illness. Cause items indicate either an internal or an external source as the cause of the myocardial infarction. Items are scored from 1 to 5, with reverse scoring when appropriate.

Summed IPQ scores were used to quantify each patient’s perception of illness as being more or less positive or negative. Higher scores on the IPQ indicate a more negative perception of illness. Higher scores on the IPQ subscales indicating a larger number of somatic symptoms, a strong belief about internal causes of illnesses, belief that the illness would last a long time, greater perceived consequences of illness, and an inability to control or cure the illness are indicative of a negative perception of illness. The IPQ has been used with a variety of subjects with acute and chronic illnesses, including heart disease and myocardial infarction.^8,10,22 The IPQ is internally consistent (Cronbach = .73–.82) and reliable (test-retest .34–.55, P < .001).²² Reliability of the IPQ in our study was good for the total score (Cronbach = .82). The change in the Cronbach when an item was deleted did not suggest improvement in the internal consistency of the IPQ. Thus, no items were deleted. Concurrent, discriminant, and predictive validity have been established with patients who had myocardial infarction.²²

  Spielberger State Anxiety Inventory.   The SSAI is a 20-item Likert scale used to measure the current level of anxiety.²⁵ The SSAI specifically measures the qualities of apprehension, tension, nervousness, and worry.²³ Subjects rate the statements of how they are feeling at the current time on a scale ranging from not at all to almost always. Individual items are scored from 1 to 4; higher scores reflect higher anxiety.

The instrument is internally consistent (Cronbach = .93) in the general population and in patients with cardiac disease.^4,26 Test-retest reliability is relatively low (.34–.62) as would be expected with a transitory concept such as state anxiety.²³ In our sample of 51 men and women with myocardial infarction, the Cronbach for the SSAI was .94. Construct, concurrent, and content validity of the SSAI were established previously with the general population and in patients with cardiac disease.^4,25,26

  Beck Depression Inventory.   The second edition of the BDI, a 21-item instrument, was used to measure levels of depressive symptoms. Subjects report the severity of symptoms on a Likert scale ranging from 0 (none) to 3 (severe); possible total scores range from 0 to 63. The higher the score on the BDI, the greater is the severity of depressive symptoms.²⁷ Scores are interpreted as indicating minimal depression (0–13), mild depression (14–19), moderate depression (20–28), and severe depression (29–63).²⁴ The second edition of the BDI does not include the physical indicators of depression that were previously criticized for possibly causing spurious elevations in BDI scores in patients with cardiac disease.²⁴ The BDI, however, has been used in a number of studies of patients with cardiac disease and is considered a valid measure of depression in cardiac patients.^4,26,28

The BDI is internally consistent and reliable in patients with cardiac disease and in the general population (Cronbach = .86 for psychiatric patients and .81 for nonpsychiatric patients).^27,29 In our sample of patients, the BDI was internally consistent (Cronbach =.88). The BDI is also a valid measure of depression. Concurrent validity was established with the general population and with patients with cardiac disease.²⁸ Depression levels measured with the BDI are not correlated with changes in age, and BDI scores for men and women do not differ.²⁹

  Complications.   Complications were determined by chart audit after patients were discharged. Complications assessed included ventricular tachycardia, ventricular fibrillation, atrial tachycardia, atrial fibrillation, bradycardia, second-degree heart block, third-degree heart block, myocardial ischemia, congestive heart failure, cardiac arrest, reinfarction, and cardiac death. Ventricular tachycardia was defined as greater than 10 consecutive beats of ventricular origin. Myocardial ischemia was defined as any chest pain requiring treatment (nitroglycerin or ß-blocking agents) or accompanied by changes in the ST segment. Congestive heart failure was defined as the presence of respiratory crackles requiring treatment with diuretics or positive inotropic agents or as documentation of the abnormality by the attending physician.

  Socioeconomic Status.   Socioeconomic status was measured as an index. The index combined self-reported job classification (based on lifetime occupation), income level, and years of education.^30,31 Job categories were assigned a score of 1 to 6; higher scores reflect jobs with the most decision latitude. Manual workers, who had little if any decision latitude, received a score of 1.³² Income levels were assigned a score of 1 to 11. Patients with an annual family income greater than $100 000 were assigned a score of 11. Patients with an annual family income less than $10000 were assigned a score of 1. These 3 scores were added to create the measure of socioeconomic status. Higher scores indicate greater socioeconomic status.

  Health History and Clinical Data.   Health history obtained at the time of recruitment included medical history related to CAD, depression, and anxiety. For each patient, the history of cardiac procedures was noted along with smoking and alcohol use. Clinical data included information on the site of myocardial infarction, laboratory data confirming acute myocardial infarction, left ventricular ejection fraction, use of thrombolytics, complications, and cardiac procedures performed.

Data Analysis
Data were analyzed by using SPSS, version 10.1.³³ Sociodemographic and clinical data were described by using frequencies, percentages, means, and SDs as appropriate. Hypotheses were tested by using logistic regression at a .05 level of significance. In this predictive analysis, the independent variables were entered hierarchically. Age, sex, and socioeconomic status were entered first; left ventricular ejection fraction and treatment with thrombolytics were entered next. Last, the IPQ score was entered. The occurrence of complications was entered as the dependent variable with 1 = the occurrence of 1 or more complications and 0 = no occurrence of a complication.

	Results

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Characteristics of the Sample
A total of 52 patients were recruited. One patient, a woman, could not complete the study because she experienced severe nausea and vomiting shortly after completing the first instrument. Two patients, both men, did not have data on left ventricular ejection fraction determined by cardiac catheterization or echocardiography in their records. One of the men had a history of renal insufficiency; the reason for not measuring the ejection fraction for the second man was not documented in the medical record. Thus, the 49 subjects who completed the study and had a documented ejection fraction were included. Equal numbers of men and women were enrolled by using oversampling of women. The mean age of the sample was 60.8 years (SD = 13.32 years), and the majority of subjects had some education beyond high school (mean = 13 years, SD = 2.38 years). All subjects in the sample were white. This unintended result can be explained by the setting. The medical center is located in the Midwest close to a predominantly white suburb. Other characteristics are given in Table 1.

A total of 44.9% of the patients experienced 1 or more complications (Table 2). ² analysis indicated no significant differences between men and women in the frequency of complications.

Relationship Between Illness Representation, Anxiety, and Depression
A simple correlation was done to examine the relationship between IPQ scores and both SSAI and BDI scores. Anxiety, as measured by SSAI scores, was moderately correlated (Pearson r = 0.563, P = .01)³⁴ with illness representation, measured by IPQ scores. As anxiety increased, illness representation became more negative. Depression, as measured by the BDI, was moderately correlated (Pearson r = 0.510, P = .01)³⁴ with illness representation. As depression increased, illness representation increased.

Prediction of Complications on the Basis of Illness Representation
The logistic regression model testing the prediction of complications (coded as 0 = no complications, 1 = 1 or more complications) was significant (² = 16.9, df = 6, P = .01). This finding indicated that when selected sociodemographic and clinical variables (left ventricular ejection fraction and treatment with thrombolytics) were controlled for, IPQ scores were predictive of the likelihood of the occurrence of any complication (B = 0.05, Wald = 4.442, P = .04, Exp(B) = 1.051, 95% CI = 1.003–1.101). Thus, when all other independent variables were kept constant, for each 1 unit increase in IPQ score, the odds of having a complication increased by 5.1%. Only IPQ score was a significant predictor of the occurrence of complications. Overall, 75.5% of the occurrences of complications were predicted correctly. The model explained 29.2% to 39.2% of the variance in the occurrence of complications (Cox and Snell R² = 0.292, Nagelkerke R² = 0.391). The classification for the dependent variable is presented in Table 3; logistic regression statistics, in Table 4.

	Discussion

Top Abstract Self-Regulation Model of Illness Background Methods Results Discussion Recommendations for Future... Conclusion References

 
Our findings support the SRMI. The results of hierarchical logistic regression analyses support the concept of self-regulation of health via illness representation. As illness representation became more negative (ie, IPQ score increased), the odds of experiencing a complication increased by 1.051. The results did not support the mediating effects of depression and anxiety. Thus, a patient’s illness representation of myocardial infarction had an impact on the likelihood that he or she would experience a complication.

A variety of concepts can be considered when the construct of illness representation is examined. Health perception, cognitive orientation, cognitive appraisal, and meaning of illness are all conceptually similar to illness representation. Previous studies of health perception at the time of myocardial infarction indicated a significant relationship between negative health perception and (1) decreased return to work,³⁶ (2) neurosis, and (3) the occurrence of inadequate support.³⁷ Ladwig et al³⁸ found a relationship between negative health perception and sleep disorders, depression, and anxiety in persons with CAD. Positive cognitive orientation has been correlated with positive life adjustments and medical recovery after myocardial infarction.^39,40 Cognitive appraisal of myocardial infarction as a threat or harm has been associated with higher levels of depression and anxiety.⁴¹

Our study was the first in which all of the attributes of illness representation were examined in a single group of patients with myocardial infarction. Our findings are consistent with the current literature on illness perception but also provide new information about the relationship of multiple psychological and physiological variables to illness representation.

Psychological aspects of illness significantly affect patients’ outcomes after myocardial infarction.

 

The finding of a significant relationship between illness representation and the occurrence of complications is the first demonstration of a direct link to physical outcomes after myocardial infarction. Petrie et al¹⁰ studied illness representation as a predictor of psychological distress and return to work in patients with myocardial infarction. We did not find any studies of the relationship between illness perception and physiological variables. However, when considered in light of the moderate correlations between illness representation and anxiety and depression in our study, a significant relationship between illness representation and the occurrence of complications is congruent with the findings of previous studies. Symptoms of anxiety after myocardial infarction have been associated with an increased likelihood of complications,⁵ smoking behavior,⁴² and diminished physical function.⁴³ Symptoms of depression have been associated with mortality,^6,44,45 reduced heart rate variability,⁴⁶ angina,^43,47,48 and decreased return to former leisure and social activities.^43,49

The results of the hierarchical logistic regression analyses support the SRMI. As illness representation became more negative (ie, IPQ score increased), the odds of experiencing a complication increased by 1.051. The mediating effects of depression and anxiety were not supported.

In this sample of patients with myocardial infarction treated with percutaneous transluminal coronary angioplasty, the model of self-regulation of health through illness representation was supported. Patients with more negative perceptions of their health were more likely to experience complications during hospitalization for the acute event than were patients with more positive perceptions. Anxiety and depression did add to the likelihood of the occurrence of complications after myocardial infarction in this sample.

	Recommendations for Future Research

Top Abstract Self-Regulation Model of Illness Background Methods Results Discussion Recommendations for Future... Conclusion References

 
Further research on illness representation after myocardial infarction and the importance of its impact on recovery is needed. Data from larger samples of patients with myocardial infarction from diverse settings and race are needed. Extending the examination of outcomes beyond the acute event is important. Studies of the relationships among illness representation and outcomes such as rehospitalization, functional ability, and mortality are also needed. In addition, studies of illness representation of myocardial infarction are needed in which subjects are not excluded on the basis of type of treatment. These investigations would provide the additional data needed to develop interventions that focus on altering perceptions of illness. Moderating a patient’s negative representation of illness to a more positive one may contribute to decreases in morbidity and mortality after myocardial infarction. Further study would also be enhanced by examining the individual attributes of illness representation to determine their contribution to recovery from myocardial infarction.

Some interventions are likely to be successful in changing illness representation. Garrity and Garrity⁴⁸ described 2 strategies that were successful in increasing adherence to the medical regimen and blood pressure control in patients with hypertension: interventions to encourage patients’ active participation in their care and social support interventions. Interventions to encourage that patients played an active role emphasized the importance of the individual patient’s being responsible for self-care. In social support interventions, a resource person was provided to assist patients in meeting the challenges of the illness. The subsets of the population with CAD and hypertension overlapped.⁴⁸ In our sample, 51% of the patients had a history of hypertension. Therefore, interventions that were successful in the treatment of hypertension most likely will be successful in the treatment of myocardial infarction.

Further exploratory research of the mechanism by which illness representation affects recovery after myocardial infarction is needed. Our data indicate a strong relationship between illness representation and recovery; however, the physiological explanation for the relationship is unclear.

Our findings reinforce the need for healthcare practitioners in acute care settings to be aware of the meaning and significance of illness to patients recovering from myocardial infarction. The data indicate the need to be sensitive to the psychological as well as the physical aspects of illness. Interventions directed at increasing patients’ active participation in self-care and a personal sense of responsibility for health should be routinely included in the care of patients recovering from myocardial infarction. Healthcare practitioners also need to identify sources of social support for patients recovering from myocardial infarction. Recommended lifestyle changes include diet modification, increased exercise, adherence to the medication regimen, and smoking cessation.⁵⁰ The findings of Frasure-Smith et al⁴⁴ support the efficacy of these interventions.

Interventions that increase patients’ participation in healthcare and provide social support most likely will be important in changing illness representation after myocardial infarction. These 2 interventions may assist in changing negative perceptions. Acute care nurses can intervene to assist patients in psychological as well as physical recovery from myocardial infarction.

	Conclusion

Top Abstract Self-Regulation Model of Illness Background Methods Results Discussion Recommendations for Future... Conclusion References

 
Illness representation after myocardial infarction has an impact on recovery. Patients with a negative representation of the meaning and significance of having a myocardial infarction are more likely to be depressed and/or anxious than are patients with a positive representation. Patients with a negative representation are also more likely to experience a complication during the acute hospital stay. Our results add to the existing literature on anxiety and depression after myocardial infarction. The findings further underscore the importance of identifying interventions to sever the link between anxiety and depression after myocardial infarction and increased morbidity and mortality. An examination of the impact of illness representation on long-term recovery after myocardial infarction will be important.

	ACKNOWLEDGMENT

 
Funding for this research was received from Epsilon Chapter of Sigma Theta Tau and Sigma Theta Tau International Virginia Henderson Clinical Research Grant.

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