Treatment Protocol and Patient Education for Heart Disease


Since patients with heart disease have a higher rate of depression, various psychological assessment measures are indicated. Physiologic, psychosocial, and behavioral factors play a key role in heart disease, and therefore, these have to be tackled with appropriate psychological interventions like education, counseling, and behavioral interventions. This essay reviews the various psychological assessment measures, physiologic, psychosocial, and behavioral factors, the goals of psychological treatment, and various psychological treatment measures. This is followed by a review of diagnostic cardiac tests, cardiac medications, and their side effects, and how a psychologist can help in dealing with some side effects.

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Psychological assessment measures in cardiac patients

Patients with cardiovascular disease have a high prevalence of depression.

This has been estimated by various studies to be between 20% and 50% (Frasure-Smith, Lesperance, & Talajic, 1995). It is therefore recommended that all cardiac patients be screened for depression during their first contact with the cardiac rehabilitation program.

These are some of the commonly used psychological assessment methods (AACVPR, 2006):

  1. Medical Outcomes Study Short Form (MOS SF-36)- This is a Health Survey-Generic health-related quality of life and functional status questionnaire, and assesses the following 9 dimensions: physical functioning, role limitations attributable to physical health problems, bodily pain, social functioning, general mental health, role limitations attributable to emotional problems, vitality, energy, or fatigue, and general health perceptions.
  2. Cook-Medley Hostility Questionnaire-This is a 50 item questionnaire.
  3. Center for Epidemiologic Studies-Depression Scale (CES-D)-This is a 20-item depression scale evaluating current (within 1 week) functioning.
  4. Beck Depression Inventory (BDI)- This is the most widely used questionnaire for assessing depression. It includes 21 self-report items.
  5. Spielberger State-Trait Anxiety Inventory-Two 20-item scales assessing current and chronic anxiety.
  6. Beck Anxiety Inventory (BAI)-for measuring the severity of anxiety through psychological and cognitive symptoms of anxiety.
  7. Herridge Cardiopulmonary Questionnaire (HCQ)-A 49-item instrument assessing hostility, depression, anxiety, stress, social support, self-efficacy, and motivation.

Other screening methods

SCID screen patient Questionnaire (SSPQ)-This is one questionnaire-type screening, which adds structured interview procedure elements into a more standardized, self-administered format (Spitzer et al., 1990).

Rafanelli et al., 2003 evaluated 61 patients after a recent myocardial infarction that participated in a cardiac rehabilitation program with both observer-rated (DSM and DCPR) and self-rated (Psychosocial Index) methods. It was found that 20% of the patients had a DSM-IV diagnosis and 30% of patients presented with a DCPR cluster, like type A behavior and irritable mood. From this, it was concluded that psychological assessment of cardiac patients needs to include both clinical (DSM) and subclinical (DCPR) methods of classification. DCPR helps to study Type A behavior in specific subgroups of cardiovascular patients (Rafanelli et al., 2003).

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Key factors that must be addressed after the diagnosis of cardiac disease

Physiological factors

A marked increase in the risk for cardiovascular disease has been associated with both type 2 diabetes and insulin resistance syndrome (Kendall & Harmel, 2002). The risk for hospitalization and death from cardiovascular disease is greatly increased by the presence of overweight and obesity.

More specifically, abdominal obesity may be associated with clustering of cardiovascular and metabolic risk factors (i.e., hypertriglyceridemia, low high-density lipoprotein [HDL] cholesterol levels, high blood pressure, and elevated levels of fasting glucose) known as the metabolic syndrome (Smith, 2007).

Many studies have indicated that the mortality after an acute myocardial infarction is higher in women than men; this is mainly attributed to age, risk factors, comorbidity, and other baseline characteristics (Trappolini et al., 2002).

Behavioral factors

Unlike traditional cardiology, which takes a mechanistic approach to heart disease, behavioral cardiology takes a broader view. According to this, although heart disease may not be inevitable, it is a consequence of unhealthy lifestyles, such as smoking, overeating, and physical inactivity, in addition to psychosocial stress (Pickering et al., 2003).

Psychosocial factors

Some psychosocial factors, which have been most thoroughly examined include chronic stress, occupational stress, anxiety, social isolation, hostility, anger, and type A behavior, socioeconomic status (SES), personality, depression, and social support.

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A causal relationship between these factors and the development of CAD has been suggested based on supportive evidence. Several pathophysiologic mechanisms have been proposed to account for CAD due to these factors. They include: the hypothalamic-pituitary-adrenal axis, hypertension, and cardiovascular reactivity, endothelial function, inflammatory markers, platelets, coagulation factors, fibrinogen, lipids, glucose metabolism, and lifestyle factors (Strike & Steptoe, 2004).

Goals for psychological treatment

The goals of psychological intervention in cardiac patients are to:

  1. Increasing the quality of life by reducing negative psychological reactions like anxiety and depression (emotions management) and increasing the chances of a return to initial activities like employment, social life, and sexual relationships (role restoration).
  2. Promote secondary prevention by increasing the knowledge and clarifying the wrong notions about heart disease and its management (knowledge), increasing the motivation for and maintenance of a healthy lifestyle (motivation; skills development and maintenance) (Coats, 1995).

Psychological interventions

  1. Education- although education is an essential psychological treatment component, by itself it cannot produce so many behavior changes as to reduce the risk factors.
    Two studies on this have concluded that education provides information for patients and families to make decisions or to increase their knowledge.
    But still many cardiac rehabilitation programs comprise mainly of exercise therapy along with some educational material. Given this, the 1995 Cardiac Rehabilitation Guideline has suggested combined counseling and behavioral intervention approach (Wenger et al., 1999).
  2. Counseling-this approach allows better interaction and exchange between the patient and the nurse or other health professional, in an atmosphere of acceptance and empathy.
    The advice, which is given during counseling is usually in response to the patient’s questions and concerns about symptoms, medications, exercise, smoking cessation, lipid management, and problems concerning competing demands on the patient’s time and other resources.
    The most commonly used counseling technique involves the assistance of the patient in active planning and problem solving. In effect, the patient receives the required support for developing a trusting relationship.
  3. Behavioral intervention-this is vital to create sustained behavior changes. Cognitive Behavioral Therapy (CBT) is a psychological treatment method using behavioral interventions and is a globally recognized and proven approach to treat anxiety, depression, and phobias.
    Recently CBT has also been applied to treat both depression and social isolation in myocardial infarction (Wenger et al., 1999). Behavioral treatment can alter both lifestyle and psychosocial factors but various barriers can impair a successful result.

These barriers include poor compliance by the patient and health care providers’ lack of skill (Pickering et al., 2003).

While behavioral interventions effectively reduce the traditional risk factors for CHD and improve the quality of life, there is not much evidence on the effectiveness of behavioral interventions for prolonging life; this requires more careful evaluation. Further investigation is also needed to determine the mechanisms by which behavioral treatments may influence clinical CHD endpoints (Blumenthal & Levenson, 1987).

Tests used to diagnose cardiac disease

There are several common noninvasive cardiac tests. These include: Resting electrocardiogram (ECG), exercise stress testing, cardiac radionuclide imaging, exercise echocardiography, electron beam computed tomography and magnetic resonance imaging.

Invasive tests include coronary angiogram (Carrier & Grudzen, 2006).

Medications prescribed and their side effects

  1. Aspirin reduces the risk of developing angina or heart attack by decreasing blood clotting. Side effects of aspirin include ulcers or bleeding problems.
  2. Nitroglycerin (sublingual NTG, isosorbide, transdermal NTG)- reduces chest pain by decreasing the oxygen demand of the heart and by dilating the coronary arteries, thereby increasing the oxygen supply. Side effects include: flushing, headache, tolerance.
  3. Calcium channel blockers (nifedipine, diltiazem, verapamil, amlodipine): Calcium channel blockers dilate the coronary arteries, reduce blood pressure, and slows the heart rate. Side effects include: flushing, hypotension, edema, worsening angina.
  4. Angiotensin-converting enzyme (ACE) inhibitors- dilates blood vessels, thereby increasing the blood flow. Side effects include: elevated blood potassium levels, low blood pressure, dizziness, headache, drowsiness, weakness, and abnormal taste.
  5. Statins: reduces lipids in the blood. Side effects include: changes in liver function, muscle pain, weakness, or tenderness.
  6. Beta-blockers (propranolol, metoprolol, atenolol): reduces the oxygen demand of the heart. Side effects include: flushing, headache, hypotension (Selwyn & Braunwald, 1998).

Some of the drugs used to treat heart disease and high blood pressure may cause erectile dysfunction and ejaculatory problems.

Both males and females might have a decreased desire or inability to have an orgasm. A psychologist can help by alleviating the fears and anxieties of a patient. It may also be helpful for the spouse to receive counseling (2007.)


There are various psychological assessment measures in cardiac patients; some of the important ones include Medical Outcomes Study Short Form, Cook-Medley Hostility Questionnaire, Center for Epidemiologic Studies-Depression Scale, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory, Beck Anxiety Inventory, and the Herridge Cardiopulmonary Questionnaire. SSPQ, DSM, and DCPR may also be useful. Some of the key factors that must be addressed after the diagnosis of cardiac disease are physiologic, behavioral, and psychosocial factors.

The goals of psychological treatment include emotions management, role restoration, increasing knowledge, and motivation, skills development, and maintenance. Psychological interventions include education, counseling, and behavioral interventions.

There are various invasive and noninvasive diagnostic tests for cardiac disease. These include: Resting electrocardiogram (ECG), exercise stress testing, cardiac radionuclide imaging, exercise echocardiography, electron beam computed tomography, and magnetic resonance imaging and coronary angiogram Some key medications include: aspirin, nitroglycerine, calcium channel blockers, ACE inhibitors, beta-blockers, and statins. The most common side effects of these medications are flushing, headache and hypotension. Some of the drugs may cause erectile dysfunction, ejaculatory problems, loss of libido, and an inability to have an orgasm. A psychologist can help by alleviating the fears and anxieties of a patient.


AACVPR, 2006. AACVPR Cardiac Rehabilitation Resource Manual: Promoting Health and Preventing Disease. Human Kinetics.

Blumenthal, J.A, Levenson, R.M (1987). Behavioral approaches to secondary prevention of coronary heart disease. Circulation. 76 (1 Pt 2): I130-7.

Carrier, E, Grudzen, C, 2006. Review of Cardiac Tests. Web.

Coats, A.J.S, 1995. BACR Guidelines for Cardiac Rehabilitation. Blackwell Publishing.

Frasure-Smith N, Lesperance F, Talajic M. (1995). Depression and 18-month prognosis after MI. Circulation. 91; 999-1005.

Kendall, D.M, Harmel, A.P (2002). The metabolic syndrome, type 2 diabetes, and cardiovascular disease: understanding the role of insulin resistance. Am J Manag Care. 8(20).

Pickering, T, Clemow, L, Davidson, K, Gerin, W (2003). Behavioral cardiology –has its time finally arrived? Mt Sinai J Med. 70(2):101-12.

Rafanelli, C, Roncuzzi, R , Finos, L, Tossani, E, Tomba, E, Mangelli, L, Urbinati, S, Pinelli,G, Fava, G.A (2003). Psychological Assessment in Cardiac Rehabilitation. Psychother Psychosom. 72:343–349.

Selwyn, A.P, Braunwald, E (1998). Ischaemic heart disease. Harrison’s Principles of Internal Medicne. Vol. 1. 14th edition. McGraw Hill.

Semmens, JP (2007). Heart Disease, High Blood Pressure, and Sexuality. Web.

Smith, S.C Jr (2007). Multiple risk factors for cardiovascular disease and diabetes mellitus. Am J Med. 20(3).

Spitzer, R.L., Williams, J.B.W., Gibbon, M, First, M.B. (1990) Structured Clinical Interview for DSM-III-R: Patient Edition. Washington, DC: American Psychiatric Press Inc.

Strike, P.C, Steptoe, A (2004). Psychosocial factors in the development of coronary artery disease. Prog Cardiovasc Dis. 46(4):337-47.

Trappolini M, Chillotti FM, Rinaldi R, Trappolini F, Coclite D, Napoletano AM, Matteoli S, (2002). Sex differences in incidence of mortality after acute myocardial infarction. Ital Heart J Suppl. 3(7):759-66.

Wenger, NK, Sivarajan, ES, Froelicher, Smith, LK (1999). Cardiac Rehabilitation: Guide to Practice in the 21st Century. Marcel Dekker.

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