Differential Long-Term Impact of In-Hospital Symptoms of Psychological Stress After Non-Q-Wave and Q-Wave Acute Myocardial Infarction Nancy Frasure-Smith, PhD, FranCok Lespbrance, MD, and Martin Juneau, MD Because of their unstable pathophysiology, it was hypothesized that patients with non-Q-wave acute myocardial infarctions (AMI) would be more vul- nerable to the negative effects of psychological stress than patients with Q-wave AMI, and thus would be more likely to benefit from programs aimed at relieving stress. This hypothesis was tested through secondary analysis of data from a l-year randomized clinical trial of psychological stress monitoring and intervention after AMI. Af- ter discharge, treatment group patients were tele- phoned each month and asked to respond to an ln- dex of psychological stress symptoms (General Health Questionnaire GHQ-20). Those with high stress symptoms (GHQ 25) received home nursing visits. Control group patients received usual care. The sample consisted of 461 men, aged 31 to 86 years, who responded to the GHQ-20 before hos- pital discharge. Patients were followed for 5 years uslng record data. There were 321 Q-wave AMls, 112 non-Q-wave AMls and 28 indeterminate elec- trocardiograms. Life-table analyses showed that among patients with non-Q-wave AMls receiving usual care, hlgh stress in the hospital (GHQ 25) was associated with a l-year relative risk (RR) of cardlac mortality of 5.49 f 1.39 (p = 0.01). In comparison, control patients with Q-wave MIS had no stress-related increase in risk (RR = 0.41 f 2.08, p = 0.40). In the treatment group, the pa- tients with non-Q-wave AMls did not experience an increase in risk associated with high stress (RR = 1.80 f 1.79, p = 0.52). Further, this pat- tern of results was not altered by adjustment for covariates including previous history of AMI. In conclusion, the link between psychological stress and cardlac events is more apparent among pa- tients with non-Q-wave than Q-wave AMI, and therefore stress-relievlng interventions may be of particular value after non-Q-wave AMI. (Am J Cardiol 1992;69:1126-1134) From the Montreal Heart Institute Research Centre, McGill Universi- ty, and the University of Montreal, Montreal, Quebec, Canada. This study was supported by the National Health Researchand Develop ment Program of Canada through Projects 605-1303-44, 6605-2388- 44.6605-2022-48 and 6605-2960-44, and by a grant from the Montreal Heart Institute Research Fund, Montreal, Quebec, Canada. Manu- script received September 10, 1991; revised manuscript received and acceptedFebruary 1,1992. Addressfor reprints: Nancy Frasure-Smith,PhD, Montreal Heart Institute, 5ooO Belanger East, Montreal, Quebec,Canada HIT lC8. i 128 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69 R ecent studieshave suggested a link betweenpsy- chological status following an acute myocardial infarction (AMI) and long-term prognosis.1-3 For example, secondaryanalysesof data from the 461 men involved in the Ischemic Heart Disease (IHD) Life StressMonitoring Program,2a randomized clinical trial of a l-year program of education and support following AMI, indicated that high levels of psychological symp toms of stress in the hospital have a long-term negative prognostic impact. Patients who had elevated scores on a measureof cognitive behavioral symptomsof psycho- logical stress(the General Health Questionnaire GHQ- 204) and who receivedusual care had a more than two- fold increase in risk of cardiac mortality over 5 years (p = 0.018), and this risk remained even after control for other cardiac risk factors. Further, patients who took part in the treatment program did not experience a significant stress-related increasein long-term risk. Perhapsthe best documentedmodel linking psycho- logical status and cardiac outcome following AM1 in- volves the combined impact of autonomic nervous sys- tem changes and myocardial ischemia on an infarct- damaged myocardium.5-7Thus, patients’ vulnerability to psychological stress may be related to underlying ischemicrisk. Work by Bissett et a1,8 as well as Gibson’s team,9has shown that patients with non-Q-waveAMIs have greater areasof residual surviving tissue in the in- farct-affected zonethan do patients with Q-wave infarc- tions. In this context it seems reasonable to suggest that patients with non-Q-waveAM1 might also be more vul- nerable to the negative effects of psychological stress, and thus might benefit more from programs like the IHD Life Stress Monitoring Program. Thus, we hy- pothesized that, in the absence of supportive/educa- tional interventions, non-Q-wave patients would be more susceptible to the negative impact of psychological stressthan Q-wave patients. METHODS Tracltment program: The details of the IHD Life Stress Monitoring Program have been described else- where.1°-12 In brief, the study involved a randomized, clinical trial of a l-year program of monthly telephone monitoring of psychological stress symptoms coupled with home nursing visits for post-AM1 patients report- ing high levelsof thesesymptoms during monthly moni- toring calls. Patients in the treatment condition were telephonedat 1 week after discharge, and every month thereafter, and askedto respondto a standardizedmea- sure of psychological symptomsof stress,the GHQ-20. MAY 1, 1992