© Borgis - Postępy Nauk Medycznych 8/2015, s. 540-544
*Alicja Nasiłowska-Barud1, 2, Mariola Żuk2, Judyta Jabłońska-Brzozowska1, 2, Andrzej Wysokiński1, Wojciech Brzozowski1
Problemy psychologiczne chorych z migotaniem przedsionków
Psychological problems in patients with atrial fibrillation
1Chair and Department of Cardiology, Medical University, Lublin
Head of Department: prof. Andrzej Wysokiński, MD, PhD
2Department of Clinical Psychology, Medical University, Lublin
Head of Department: prof. Alicja Nasiłowska-Barud, MD, PhD
Wstęp. Migotanie przedsionków (ang. atrial fibrillation – AF) jest najczęstszym zaburzeniem rytmu serca. Badania epidemiologiczne wskazują, że migotanie przedsionków występuje od 1-2% wśród światowej populacji dorosłych i liczba zachorowań stale wzrasta. Umieralność wśród osób z migotaniem przedsionków jest dwukrotnie większa niż u osób z prawidłowym zatokowym rytmem serca. Znacznie częściej również występują powikłania zatorowo-zakrzepowe, m.in. udary niedokrwienne mózgu. Także epizody przemijającego niedokrwienia mózgu są 2-7 razy częstsze niż u osób, u których nie występuje migotanie przedsionków. Tworzy to tło, na którym należy widzieć psychologiczną sytuację chorego z migotaniem przedsionków.
Cel pracy. Analiza funkcjonowania psychicznego chorych z migotaniem przedsionków.
Materiał i metody. Spośród 2337 pacjentów wyodrębniono grupę 137 chorych, którzy w 2014 roku byli leczeni z powodu migotania przedsionków w Klinice Kardiologii Uniwersytetu Medycznego w Lublinie i wymagali pomocy psychologicznej. Podczas jej udzielania uzyskano dane kliniczne pozwalające przeprowadzić analizę funkcjonowania psychicznego chorych objętych pomocą i terapią psychologiczną.
Wyniki. Pomocy psychologicznej wymagają chorzy z AF, u których występują nasilone objawy niepokoju, lęku, poczucie zagrożenia i obniżony nastrój. Specjalnego podejścia psychoterapeutycznego wymagają pacjenci z powikłaniami zasadniczej choroby. Pomocą psychologiczną należy objąć też chorych kwalifikowanych do leczenia migotania przedsionków z zastosowaniem nowoczesnych, inwazyjnych metod, jak przezskórna ablacja.
Wnioski. Pomoc psychologiczna udzielana chorym z migotaniem przedsionków winna obejmować: 1. opanowanie sfery negatywnych emocji doświadczanych w chorobie, zwłaszcza lęku przed bólem, możliwymi powikłaniami i śmiercią, 2. psychoedukację pacjenta odnośnie metod radzenia sobie z bólem, lękiem i innymi nieprzyjemnymi doznaniami, 3. wzmocnienie odporności psychicznej i motywacji chorego do zaangażowania w proces leczenia i współpracy z zespołem terapeutycznym.
Introduction. Atrial fibrillation is the most common cardiac arrhythmia. Epidemiological studies show that 1-2% of the global population of adults suffer from atrial fibrillation and the number is growing. Mortality among patients with atrial fibrillation is twice as high as in patients with normal sinus rhythm. Thromboembolic complications such as ischemic stroke are much more common too. Also transient cerebral ischemia is from two to seven times more frequent as in people who do not suffer from atrial fibrillation. This is the background which should be considered in analyzing psychological situation of patients suffering from atrial fibrillation.
Aim. Analysis of mental functioning of patients with atrial fibrillation.
Material and methods. A group of 137 patients was selected from 2337 patients who were treated for atrial fibrillation at the Cardiology Clinic of the Medical University of Lublin in 2014. Patients who were admitted to this study required psychological support. During the treatment the clinical data were obtained which allowed to analyse the mental functioning of patients provided with psychological therapy and support.
Results. Psychological therapy and support is required by patients with severe symptoms of anxiety, restlessness, insecurity and depressed mood. Special psychological therapy was also required by patients with complications of underlying disease. Special psychological therapy approach is required by a group of patients qualified for modern, invasive methods of atrial fibrillation treatment such as percutaneous ablation.
Conclusions. Psychological support provided to patients with atrial fibrillation should include: 1. controlling negative emotions experienced by patients in their illness, especially fear of pain, possible complications and fear of death, 2. psychoeducation of patients concerning methods of coping with pain, anxiety and other unpleasant experiences, 3. strengthening psychological resilience and patient’s motivation to become involved in the treatment and cooperate with doctors and psychologists.
Atrial fibrillation (AF) is the most common heart rhythm disorder. Epidemiological studies indicate that atrial fibrillation occurs from 1-2% of the world’s population of adults and the number of cases is increasing. In Europe, about 6 million people suffer from this disorder. In Poland, atrial fibrillation concerns about 400 thousand people. Prognostic studies show that over the next twenty years, the number of cases will increase twice to 800 thousand. Therefore, atrial fibrillation is a major epidemiological problem and is one of the most serious risk factors for stroke (1).
Mortality among people with AF is twice higher than in patients with normal sinus rhythm of heart. There are also more often thromboembolic complications as ischemic strokes to the brain. The episodes of brain ischemia are 2-7 times more frequent than in people with no AF.
Atrial fibrillation is defined as the most common supraventricular tachyarytmia, which is characterized by fast (350-700/min) uncoordinated atrial activation, leading to a loss of efficiency, so ventricular irregularity is accompanied by a contraction of their hemodynamic rhythm.
These are the most common features of atrial fibrillation (AF):
– atrial fibrillation diagnosed for the first time,
– recurrent atrial fibrillation – if it occurred over two episodes,
– paroxysmal atrial fibrillation ishealed spontaneously or lasts less than 7 days,
– persistent – takes more than 7 days is not healed spontaneously,
– persisted – usually prolonged attempts of cardioversion were ineffective or there were no such trials (1).
The most common causes of occurrence of AF include: age, hypertension, symptomatic heart failure, tachycardiomyopathy, valvular heart diseases, cardiomyopathies, atrial septal defect, other congenital heart defects, coronary artery disease, symptomatic of thyroid function disorders, obesity, diabetes, chronic obstructive pulmonary disease, sleep apnea, chronic kidney disease (1, 2).
According to the recommendations of the European Society of Cardiology (ESC) the symptoms of atrial fibrillation are divided according to the 4-degree scale:
I – lack of feeling symptoms,
II – mild symptoms, causing no impairment of daily functioning,
III – severe symptoms, limiting daily activities,
IV – symptoms that prevent the daily functioning.
The most frequently occurring symptoms of atrial fibrillation include palpitations, chest pain, a feeling of breathlessness, tiredness, dizziness, fainting, sweating, the worse effort tolerance, feeling of anxiety, polyuria, irregular heart rate pulse deficit (3-5).
Patients with atrial fibrillation are submitted to cardiology clinics or departments of cardiology in different stages of advancement of the disease.
Analysis of mental functioning of patients with atrial fibrillation.
MATERIAL AND METHODS
The analysis of the mental functioning in patients with AF was performed on the basis of clinical data. It was collected during the psychotherapeutic support for 137 patients from a group of 2337, who in 2014 were hospitalized in the Department of Cardiology Medical University in Lublin with atrial fibrillation diagnosed. Among the 137 patients with AF, there were 52 (38%) women aged from 43 to 77 avg. 62.3 and 85 (62%) of men aged 51 to 74 avg. 63.4 years. In 28 (20.5%) people AF occurred for the first time, while in 109 (79.5%) AF recurred, and 14 (10.2%) patients were qualified for ablation.
Detailed psychological interview was conducted with patients, and then they were supported with a psychotherapeutic professional aid.
Analysis of psychotherapeutic aid to the patients with AF enabled presentation of the most important problems with mental functioning of the patients with AF.
Discussion on the mental functioning conditions of the patients with atrial fibrillation should be started from a situation where the diagnosis is given for the first time. Usually a patient suddenly, unexpectedly begins to feel uneven heartbeat, heartbeat is sometimes very fast. The patients may feel palpitations, in addition the patient may experience pain in the chest with a feeling of shortness of breath or excessive sweating. Uneven heartbeats, chest pain and shortness of breath cause anxiety and a sense of threat. The patient is frightened by his or her health condition. He or she knows that something is wrong with their heart. According to common knowledge the appearance of the chest pain usually means myocardial infarction. In result, the patient is convinced that he or she has a myocardial infarction. Myocardial infarction is a direct threat to life. Uneven heartbeats and chest pain intensifies anxiety and anxiety increases fast heart beat and pain. The sense of threat of their own life grows. In the early stage, when there is a rapid and uneven heartbeat, patients usually do not call for professional help. They try to seek the help in a family, take medications that are available at home such as herbal drops, drops or they go to bed to rest. When these methods fail, patients decide to call for help. After the patient is placed in the emergency ward and EKG is performed, the patient receives the information that the cause of mood deterioration is atrial fibrillation, namely, abnormal heart action. The patient also receives information that there is a need to stay in the hospital and being treated to restore the normal sinus heart rhythm. The patient is usually does not know anything about his or her illness and may know nothing heart rhythm disorders.
Information about heart attacks is more common in everyday knowledge, rather than about abnormal heart rhythms. The patient is placed in a clinic or ward, and the team treating must rely on the existing guidelines of the European Society of Cardiology (ESC, European Society of Cardiology from 2010) and on their basis they must make a decision regarding the application of proper treatment, designed to restore normal sinus arrhythmia (1, 6, 7).
Among patients whose atrial fibrillation occurred for the first time there are people after myocardial infarction, after surgical treatment such as vascular arterial coronary bypass (CABG), after heart transplantation, after valvular heart diseases corrections, with heart failure, with hypertension, with cardiomyopathy, diabetes, hyperthyroidism, or chronic obstructive pulmonary disease. Patients with these diseases already have experience after a previous treatment.
Most patients need to take a decision about the treatment in the clinic or cardiology ward and it raises anxiety and insecurity of their own life. In addition, patients can also feel the anxiety from the family or loved ones. For many patients the necessity to stay in the clinic or ward is very difficult to accept, there is also a difficult adaptation to the new conditions. Patients admitted to the hospital in order to treat atrial fibrillation come from different social backgrounds. Very often there is a large distance from their place of residence to the clinic. There is also different condition of their mental functioning and the level of cognitive performance.
Usually at the time of presenting the information to the patients about the need to stay in the ward and using intensive treatment patients try to negotiate with the doctor. The patient very often gives the arguments that his or her health condition worsen due to the excessive physical excertion, limited hours of sleep, increased mental workload, etc. The patient uses the intrapsychic ways of coping in a difficult situation which are safeguard mechanisms of represive type (crowding, refuse) (8, 9).
When the doctor’s decision concerning patient’s stay in the ward cannot be changed, the patient accepts it and agrees to be in hospital, although one may not be entirely convinced that this is the best option. Usually the patient feels insecure, frightened and full of doubts. The patient says that three hours before he or she felt completely healthy and was able to complete his or her duties normally. What is more, the patient seeks for the reason of the illness in his or her previous behavior.
Once, the doctor recognised the first episode of atrial fibrillation on the basis of clinical symptoms and electrocardiographic examination the patient should be supported with professional psychological assistance.
The first phase of assistance and psychological intervention begins with the assessment of the mental state of the patient. Clinical psychologist looking after the patient performs an initial psychological diagnosis and conducts psychological therapy aimed at:
– helping the patient to control fear, distress, sometimes strong anxiety,
– ensuring the patient about his or her safety,
– reducing the mental tension,
– providing mental support (4, 10-14).
The psychological impact is mainly based on informing the patient about the place and the therapy conducted, explaining the peculiarities of treatment in a clinic/cardiology ward, informing the patient about the need to monitoring the electrical activities of the heart (EKG), and the need to monitoring blood pressure. Clinical psychologist activates and encourages the patient to talk about their own experiences and discuss all the doubts. Working with the patient, the psychologist conducts supporting therapy and psychoeducation concerning the understanding of the disease and the strengthening objective factors of recovery process. There are also gradually introduced selected relaxing exercises (15-17).
The second group are the patients with recurrent atrial fibrillation FA (if there were more than 2 episodes). Reoccurring symptoms which were once experienced, immediately evoke the anxiety and the sense of threat. Anxiety becomes more complex: it appears due to uneven heartbeats, and malaise. Anxiety is growing as a result of:
– inability to cope alone,
– the need to go to the hospital,
– concerns about the effectiveness of treatment,
– consideration of the possible complications, i.e. stroke,
– worries about the family,
– worries about patient’s own life.
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