Psychological Approach To The Rehabilitation Of Coronary Patients

The increasing frequency of coronary diseases, the still insufficient results of prevention have brought physicians to try to reduce as much as possible the con sequences of ischaemic heart disease. Coronary units and new treatments have some what reduced the dramatic complications of the acute phase; but after the latter, evil effects of the disease remain at the physiological, psychological and social level. It is the aim of rehabi~itation to analyze these problems, to reduce them or to solve them whenever possible. When this conception of "complete coronary care" took the lead, the necon ditioning effects of heart disease and of immobilization on physical conditi ons were emphasized: physical training programmes were prepared and their main lines and physiological effects are now fairly well known. But it was soon obvious that the psychological problems raised by the patient and his environment 'are equally important. Their approach is however much more difficult and their treatment particularly complex. So, the Council on Rehabilitation of the International Society of Cardiology is really grateful to Professor Dr. HALHUBER and Dr. Dr. STOCKSMEIER for giving the opportunity to specialists to discuss together this particular aspect of coronary disease. The discussions have been devoted to the methods of approaching the patient as well as to the therapeutic aspects and the role of psychologists in the rehabilitation programmes: some papers have been devoted also to the possible role of the personality as a risk factor in the development of the disease.

The increasing frequency of coronary diseases, the still insufficient results of prevention have brought physicians to try to reduce as much as possible the con sequences of ischaemic heart disease. Coronary units and new treatments have some what reduced the dramatic complications of the acute phase; but after the latter, evil effects of the disease remain at the physiological, psychological and social level. It is the aim of rehabi~itation to analyze these problems, to reduce them or to solve them whenever possible. When this conception of "complete coronary care" took the lead, the necon ditioning effects of heart disease and of immobilization on physical conditi ons were emphasized: physical training programmes were prepared and their main lines and physiological effects are now fairly well known. But it was soon obvious that the psychological problems raised by the patient and his environment 'are equally important. Their approach is however much more difficult and their treatment particularly complex. So, the Council on Rehabilitation of the International Society of Cardiology is really grateful to Professor Dr. HALHUBER and Dr. Dr. STOCKSMEIER for giving the opportunity to specialists to discuss together this particular aspect of coronary disease. The discussions have been devoted to the methods of approaching the patient as well as to the therapeutic aspects and the role of psychologists in the rehabilitation programmes: some papers have been devoted also to the possible role of the personality as a risk factor in the development of the disease.

When I gave a presentation on return to work after heart valve replacement at the Tenth Congress of the German Society for Thoracic and Cardiovascular Surgery in 1981, I was surprised by the relatively low level of interest that cardiac surgeons seemed to have in this subject. This stimulated me to intensify my research in this area and to extend it to patients with coron ary heart disease. Obviously, physiological and mechanical aspects of medical treatment are of special interest to the surgeon. For the majority of cardiac surgical patients, that is those with coronary heart disease, the technical problems of the operative procedure have been solved to a great extent. Many studies have demonstrated that, aside from reduction of symptoms, aortocoronary bypass operation can lead to improvement of cardiac performance un der stress conditions. However in spite of the technical solutions to hemodynamic problems, it has become very clear that the reintegration of patients into their social sphere has not been accomplished to the extent that might be expected, as exempli fied by the relatively low rate of postoperative return to work.

Heart surgery is still a relatively recent advance in medical technology. The first open-heart procedure was closure of an atrial septal defect in a child at the University of Minnesota Hospital in 1953. This issued in a life-saving advance, the use of which has expanded enormously to in clude treatment of many areas of cardiac disease. Not unexpectedly, surgical techniques allowed through the use of the heart-lung machine (open-heart surgery) came to be applied in 1967 to the major killer of Americans, namely, coronary artery disease. This operation, known as coronary artery bypass, has become one of the most common surgical operations. Coronary artery disease, with the possibility of total incapacitation or sudden death from a heart attack, can alter severely the personality of the patient. Corrective surgery can sometimes intensify rather than ame liorate a patient's fears. To the surgeon, occupied by increasing numbers of patients, there is not time enough to give the preoperative attention that might be helpful. Also, the surgeon and cardiologist are limited in their ability to recognize those patients near the breaking point. The research outlined in these chapters by Drs. Pimm, Feist, and their associates is welcomed by cardiologists and cardiac surgeons. It provides insight into what appears to be reliable recognition of those patients likely to have an adversely affected mental status by coronary bypass surgery and "crisis intervention" to avert this effect and allow the complete benefit of returning the patient to a normal life.

The papers presented in this book were held at the International Sym posium on "Prognosis of Coronary Heart Disease - Progression of Cor onary Arteriosclerosis" on October 22 and 23, 1982 in Bad Krozingen, FRG on the occasion of the 10th anniversary of the Rehabilitationszen trum Bad Krozingen. The symposium was sponsored and supported by the European So ciety of Cardiology and the Pharma Schwarz Co. The scientific com mittee was composed of F. Loogen (Dusseldorf), P.G. Hugenholtz (Rotterdam), and the editor of this book. To all of these and to my co-workers many thanks. Bad Krozingen, August 1983 H. Roskamm Table of Contents W. Steinbrunn and P.R. Lichtlen Prognosis of Patients with Coronary Heart Disease Evaluated Using Data Obtained by Invasive Methods ... 1 R.A. Bruce Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Noninvasive Methods ... 16 K. Bachmann, W. Niederer, H. Fuchs, and H. Holzberger Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Invasive and Noninvasive Methods ... 24 R. Balcon, M. Cattell, and K. Wong Prognosis of Coronary Heart Disease Patients Evaluated by Data Obtained by Angiography and Exercise Testing ... 36 M. Kaltenbach and W.-D. Bussmann Prognostic Relevance of Findings from Invasive and Noninvasive Investigations in Coronary Heart Disease Patients ... 44 H. Gohlke, L. Samek, P. Betz, and H. Roskamm Prognostic Relevance of Invasive and Noninvasive Data in Angiographically Defined Subgroups of Coronary Heart Disease Patients ... . 54 v. F.

Prospects of Heart Surgery: Psychological Adjustment to Coronary Bypass Grafting reports on a study of how patients and their spouses adjusted to the prospect, and then to the outcome, of coronary graft surgery. The focus upon patients' social relationships rather than upon individuals reveals that the way people bear their illness, and adapt to symptom removal, is part of a wider adjustment involving both the spouse and other individuals. The book offers, as one of its main contributions, a social-psychological approach to the study of illness in general. It sets out a new methodology which might be applied in a number of illness contexts. Using both qualitative and quantitative analyses, Prospects of Heart Surgery describes differences between smooth and problematic approaches to surgery as well as variations in the experience of rehabilitation afterwards.