2025+AHA科学声明：心肌梗死后心理困扰

METHODOLOGY

To develop this scientific statement, writing group mem-bers were identified and selected on the basis of a broad array of relevant areas of expertise, specialties, and pri-mary practice settings. Relevant studies for analysis were

identified from PubMed with search terms including de-pression, anxiety, stress, PTSD, psychological distress,emotional distress,MI,and ACS. Factors considered in evaluating study data included observational versus ex-perimental(clinical trial) design, sample size, association versus causation, clinical outcomes measured, quality of the psychological assessment, and duration of follow-up.This document focuses on the most relevant findings of those publications and strives to synthesize and summa-rize this information in a manner designed to raise the health care community's awareness of PMPD and to of-fer basic guidance in its recognition and initial triage.

For summarized study results, odds ratios, hazard ratios(HRs),95% Cls,and P values are included when given in the study articles. In accordance with efforts to keep scientific statements concise and readable, this article is not all inclusive but rather highlights key issues in a manner suited for busy health care practitioners. All writing group members reported no relevant relation-ships with industry or conflicts of interest. The manu-script was written, reviewed, and approved by all writing group members and then underwent formal review by external reviewers and the American Heart Association leadership.

# ADVERSE CLINICAL CONSEQUENCES OF PMPD

There is a growing body of data that PMPD is associated with future adverse cardiac events. In the national SWE-DEHEART(Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) regis-try of 26 641 patients with a first-time Ml, psychological distress was assessed 2 and 12 months after the Ml.The HR for patients with persistent emotional distress(21%of patients) compared with those with no distress for car-diovascular mortality was 1.46(95% CI, 1.16-1.84).23 An Australian study found a“dose-response” relationship between the degree of psychological distress after MI(or after stroke) and future cardiovascular risk. After a mean of 4.7 years of follow-up, moderate psychological dis-tress was associated with a 28% increased risk of future MI(HR, 1.29[95% CI, 1.15-1.43]) and high/very high distress was associated with a 60% increased risk(HR,1.60[95% CI,1.38-1.86]) compared with low distress.24

There is substantial evidence that depression after MI is associated with a doubling of the risk of recurrent cardio-vascular events and mortality.25,26 This association is pres-ent whether depression is defined by a clinical diagnosis(ie, major depressive disorder) or by a self-report symptom severity measure.26 Based on the strength of the evidence linking post-MI depression with increased cardiovascular risk and mortality, a 2014 American Heart Association scientific statement recommended that depression should be elevated to the status of a risk factor in patients with

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an MI or other types of ACSs.34 Some studies have sug-gested that certain subtypes or symptoms of depression such as anhedonia or incident depressive symptoms after MI are associated with higher risk, but these findings have not been consistently replicated.35-38

The evidence linking anxiety to increased cardiovas-cular risk and mortality is more mixed.39-43 The prepon-derance of evidence suggests that anxiety is associated with increased cardiovascular risk in patients with a his-tory of MI, although possibly of a lower magnitude than depression.39 In 1 study, almost 300 post-MI patients were assessed in hospital and 4 months later with the Cardiac Anxiety Questionnaire, which assesses fear,attention, avoidance of physical exercise, and safety-seeking behavior.41 During a mean follow-up of 4.2 years,Cardiac Anxiety Questionnaire-measured anxiety dur-ing hospitalization was associated with an HR of 1.59(95% CI, 1.04-2.43; P=0.033) for major adverse cardiac events.The HR based on the Cardiac Anxiety Question-naire score measured 4 months after discharge was 1.77(95% CI, 1.04-3.02; P=0.036). Avoidance of physical activity was found to be a major driver of the increased HR.In a meta-analysis of 12 studies consisting of a total of 5750 post-MI patients followed up for an average of 2.6 years, the odds ratio for the combined end point of cardiac event, cardiac mortality, and all-cause mortal-ity in those with anxiety was 1.36(95% CI, 1.18-1.36;P<0.001). The odds ratio for a new cardiac event was 1.71(95% CI, 1.31-2.23; P<0.001) and for cardiac mortality was 1.23(95% CI, 1.03-1.47; P=0.02).

Acute stress has been shown to be associated with increased risk of Ml, ventricular arrhythmias, and sudden death.44 For example, daily mortality around the time of the Northridge earthquake in 1994 was associated with a 5-fold increase in sudden cardiac deaths on the day of the earthquake.45 Chronic stress is associated with an≈40% to 60% increased risk for future adverse cardiac events such as MI.44,46,47 Few data have specifically evalu-ated stress after MI and future cardiac risk. In 1 cohort study of 4204 post-Ml patients from 24 American hospi-tals who completed the Perceived Stress Scale-4, those with moderate or high stress(compared with low stress)reported more frequent angina and had an increased 2-year adjusted all-cause mortality rate(12.9% versus 8.6%;P<0.001). Cardiac mortality was not reported.48

Several studies have examined the impact of MI-induced PTSD on prognosis. In a study of 297 patients who self-rated PTSD symptoms attributable to a previ-ous index MI, after a mean follow-up of 2.8 years, those with higher PTSD symptoms had an adjusted HR of 1.42(95% CI, 1.07-1.88) for cardiovascular disease-related hospital readmission.49 A meta-analysis of 3 studies found a doubling of risk for recurrent cardiovascular events or mortality in patients who develop PTSD symp-toms related to an MI.50 The risk ratio was 2.00(95% CI,1.69-2.37).

Depression, anxiety, and PTSD after MI have been associated with not just worse prognosis but also lower quality of life.51-53 Although PTSD(as well as depres-sion and anxiety) often remits over time after a traumatic event such as an MI, 1 study showed that early PTSD symptoms after an MI or other types of ACS were asso-ciated with poorer quality of life even 8 years later.54

MECHANISMS BY WHICH MI MAY INDUCE PMPD

Several plausible mechanisms by which Ml may induce PMPD have been proposed, although this field of in-vestigation is in its early stages. Ischemic injury caused by an Ml triggers the release of proinflammatory cyto-kines, which can influence the brain through various pathways, including the hypothalamic-pituitary-adrenal axis and the autonomic nervous system.55 This can in-duce depressive-like symptoms such as withdrawal,inactivity, and social disengagement. This behavior pat-tern is sometimes called sickness behavior to highlight its evolutionary function to conserve energy to promote recovery.56 The activation of the hypothalamic-pituitary-adrenal axis and autonomic nervous system can also result in excessive arousal and vigilance, which are key symptoms of stress, anxiety, and PISD57 In addition,el-evated levels of inflammatory cytokines are associated with increased activity of an enzyme that degrades tryp-tophan(a serotovin precursor), likely resulting in lower levels of serotonin. This may represent another mecha-nistic link that connects inflammation to depression in patients with cardiac disease.58

Psychologically, an MI is a life-threatening event that may act as a trauma, potentially leading to PTSD.Even when PTSD criteria are not met, the MI can act as a conditioning event, leading an individual to associ-ate health- and heart-related stimuli with fear.59,60 This fear can promote avoidance of situations that remind the patient of the event or the possibility of dying such as physical activity. Avoidance, in turn, can lead to a more chronic fear of the stimuli avoided through learning pro-cesses.60,61 Avoidance is also relevant to the development of depression; patients may stop engaging in previously enjoyable activities and isolate themselves socially.62,63 Interoceptive bias, characterized as increased atten-tion and distress related to bodily sensations, may also contribute to patients' likelihood of developing PMPD.64 Among a sample of patients who were admitted for ACS,those with high compared with low symptoms of PTSD after discharge had a 73% greater adjusted odds of fear about cardiac activity during physical activity and 35%greater odds of avoiding physical activity.65

Socioeconomic factors may be detrimental to an individual's coping ability and contribute to PMPD. For example, a large registry-based study showed that

CLINICAL STATEMENTS AND GUENDELINES

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unemployed patients with a history of MI have a doubled risk of PMPD compared with employed patients.22 The influence of socioeconomic factors may also be ampli-fied by the fact that socioeconomic factors influence information about, referral to, and patients' willingness to participate in cardiac rehabilitation.66

MECHANISMS BY WHICH PMPD MAY INCREASE CARDIAC RISK

Numerous mechanisms may contribute to the observed increase in adverse cardiac events in patients who de-velop PMPD.Psychological distress is known to be a risk factor for the development of cardiac risk factors, includ-ing smoking, diabetes, sedentary lifestyle, and obesity.There is substantial evidence that depression after MI negatively affects multiple health behaviors that are im-portant for reducing risk of recurrence.This may result in physical inactivity, inadequate sleep, poor diet, smoking,reduced adherence to cardiovascular medications, and poor attendance at cardiac rehabilitation.68,69 Different explanations have been suggested for these associa-tions such as an inability to follow recommended behav-iors, low energy and fatigue, impaired motivation, and cognitive deficits. Depression has also been associated with altered autonomic nervous system activity, includ-ing low heart rate variability, elevated heart rate, elevated catecholamine levels and inflammatory activity, greater platelet reactivity, and endothelial dysfunction.70,71

Anxiety is also associated with poorer health behav-iors such as cigarette smoking, excess alcohol consump-tion, lower physical activity, and poor diet, which increase the risk of cardiovascular disease.72-74 Cardiac anxiety has been associated with lower adherence to multiple health behaviors.75,76 Post-MI PTSD has similarly been linked to poor health behaviors. In a study that assessed the association between PTSD and medication adher-ence as measured by an electronic pill bottle that tracked the date and time the bottle was opened, patients with elevated PTSD symptoms after ACS were twice as likely to be nonathercent to the medication regimen."

Acute psychosocial stress can lead to coronary vaso-constriction,myocardial ischemia, and left ventricular wall motion abnormalities.44 Studies have demonstrated that 20% to 70% of adults with coronary heart disease have ischemia in response to acute psychological stress. ${}^{78}$ As noted previously, such stress is associated with a notable increased risk of Ml, ventricular arrhythmias, and sudden death. With regard to chronic stress, chronic sympathetic nervous system stimulation attributable to stress leads to increased blood pressure.44 Chronic stress has been associated in some but not all studies with elevated C-reaction protein, inflammatory cytokines, and arterial inflammation.44

Although these findings are associative, randomized trials of“inducing” PMPD compared with not inducing

PMPD are obviously unethical and implausible, and these findings provide multiple biologically plausible mecha-nisms that could increase risk of future cardiac events in those with PMPD. In addition, given the many candidate factors that may increase cardiac risk, identifying the one or several that actually do mechanistically increase risk remains challenging.

RECOGNITION AND SCREENING

PMDP is often first apparent in a patient's presentation in clinic. Key characteristics of depression may include sad mood, hopelessness, and loss of interest or plea-sure in normal activities. Patients with anxiety can have excessive worry or irritability, and those who develop symptoms of PTSD may report nightmares or intrusive thoughts about their cardiovascular event or excessive worry or fear about a future event. Those experiencing elevated psychosocial stress endorse feeling irritable,overhewed, and unable to manage or control their per-sonal responsibilities and may exhibit or report telltale signs such as poor sleep, diet, avoidance of physical ac-tivity, withdrawal from social engagement, and increased stress.1079-81 Post-MI distress may also be signaled by decreased engagement in follow-up care and difficulty following clinical recommendations.

There is debate about whether to deploy systematic screening tools for depression or other common types of distress in post-Ml patients. Although several studies have demonstrated that screening in patients with car-diovascular disease is feasible,8283 a recent clinical trial of systematic screening and postscreening treatment for post-ACS depression showed no benefit for improving quality of life or reducing depressive symptoms.82

Common screening instruments may be useful for pro-viding examples of the key questions that clinicians can use to ask patients in whom there is a identified concern about depression,anxiety,psychosocial stress, or PTSD.Given the paucity of data that clearly support routine screening, however, there is no consensus at this time to recommend the general use of such screening tools on every patient after MI. That said, for those who are interested in screening of patients or further investiga-tion in patients who seem to potentially have PMPD, the following information is provided. For efficiency, psycho-logical distress can first be evaluated with brief, patient-administered screening tools. One preferred frontline approach is using the 4-item Patient Health Question-naire,84 which combines 2 questions about depression symptoms and 2 questions about anxiety symptoms over the prior 2 weeks(Table 1).85 The 5-item Primary Care PTSD Screen for DSM-5 is a brief, well-validated instrument86 that characterizes symptoms in reference to a traumatic experience in the past month. In relation to psychosocial stress, the 4-item Perceived Stress Scale is a well-regarded brief assessment that is used to query

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Table 1. The 40-item Patient Health Questionnaire

|Over the last 2 wk, how often have you been bothered by the following problems?|Not at all|Several days|More than half the days|Nearly every day| |---|---|---|---|---| |Feeling nervous, anxious, or on edge|0|1|2|3| |Not being able to stop or control worrying|0|1|2|3| |Feeling down, depressed, or hopeless|0|1|2|3| |Little interest or pleasure in doing things|0|1|2|3|

Total score is determined by adding together the scores of each of the 4 items.Scores are rated as normal(0-2), mild(3-5), moderate(6-8), and severe(9-12).

Reproduced with permission from Kroenke et al.85 Copyright© 2009 Wolters Kluwer Health.

experiences over the past month that uses 4 questions on feelings and thoughts over the past month, each rated on a scale of frequency from 0 to 4.87,88 More extensive instru-ments are also available to capture psychological distress in each domain, including the 8-item Patient Health Ques-tionnaire,89 9-item Patient Health Questionnaire,90 7-item Generalized Anxiety Disorder scale,91 14-item Hospital Anxiety and Depression Scale,92 20-item PTSD Check-list for DSM-5,93 and 10- or 14-item Perceived Stress Scale.87,88,94 Although these psychological assessments can be implemented in any cardiovascular care setting,most evidence is based on cardiac rehabilitation.95 If rou-tine screening is adopted, it is recommended that the approach includes an established pathway for additional,advanced assessment and psychological health treat-ment, and models are available for offering this integrated treatment within cardiovascular medicine.396 Of note,when mental health symptoms are assessed in those with physical illness, it is particularly important to inquire about cognitive symptoms(eg, depressed mood, loss of interest,or recurrent worry) rather than focusing solely on somatic symptoms(eg, sleep or energy), which may be referable to the medical illness.

INITIAL TREATMENTS AND REFERRAL

Numerous studies have examined the impact of men-tal health treatments for depression and anxiety among those with cardiovascular disease. In terms of medication treatments for depression, several trials of antidepres-sants(primarily selective serotonin reuptake inhibitors[SSRIs], with sertraline the most studied agent) have found these agents to be safe and well tolerated among those with recent MI or more chronic coronary artery disease(CAD).97-101 In terms of medication efficacy,SSRs have consistently led to improvements in mood symptoms in clinical trials of individuals with recent MI or more chronic cardiac disease,97-101 with a recent um-brella meta-analysis(covering 23 meta-analyses) find-

ing that antidepressants improved depression after MI with a large standardized mean difference(1.38[95%CI, 0.82-1.93]) compared with placebo.102 No well-powered study has assessed whether antidepressants lead to improved cardiac outcomes after MI. Data from clinical trials and observational studies suggest that SS-RIs may lead to superior cardiac outcomes, including decreased risk of MI, potentially more so than other de-pression treatments,103-106 although some observational studies have found neutral or negative effects of SSRIs on mortality and cardiac health,107 Other medications may be indicated for depression in those with cardiovascular disease. The antidepressant bupropion has been found to be safe at therapeutic doses immediately after an ACS.108,109 Mirtazapine is another antidepressant agent found to be safe and efficacious in cardiac patients after an MI,110 although it can increase weight.

A Bayesian random-effects meta-analysis found that in patients with ACS and depression, antidepressant therapy compared with usual care or placebo reduced the odds of recurrent MI(odds ratio, 0.45[95% CI,0.25-0.81]).111 As with many studies, those who posi-tively responded to therapy, with in this case decreased depression, tend to be the ones who have a reduction in adverse cardiac events.112 In contrast, a recent network meta-analysis of 12116 individuals from randomized controlled trials in the treatment of post-ACS depression after ACS found that although treatment resulted in a significant decrease in depressive symptoms, there was no relationship between antidepressant treatment and recurrent MI or mortality.113 There have been no large,specific trials of SSRIs for trauma- or anxiety-related conditions among individuals with CAD, although 1 trial in patients with CAD found escitalopram to be superior to exercise or placebo in reducing anxiety over a 1-year period.114,115 Likewise, there have been no large tri-als of other antianxiety agents(eg, benzodiazepines) in patients with CAD.

Along with medications, psychological treatments may provide benefit for depression and anxiety in patients with CAD. The most common such treat-ment is cognitive behavioral therapy. Traditional cog-nitive behavioral therapy techniques are, for example,exposure therapy for anxiety, behavioral activation for depression, and cognitive restructuring for dysfunctional beliefs about the disease and the patient's present situ-ation. More modern techniques include mindfulness and value-oriented approaches such as acceptance and commitment therapy.

Randomized controlled trials of cognitive behav-ioral therapy have led to benefit for mood and anxiety symptoms in individuals with recent Ml, coronary artery bypass graft surgery, and more chronic cardiovascular disease.116-119 Other evidence-based psychotherapies(eg, mindfulness-based stress reduction) have been effective in those with mood or anxiety disorders in the

CLINICAL STATEMENTS AND GUDEGLYELS

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general population and have shown benefits of mental health symptoms and cardiovascular risk factor reduction in patients with CAD120-122; however, no randomized con-trolled trials examining mindfulness-based stress reduc-tion in patients with CAD have been identified. Of note,moderate exercise has demonstrated substantial antide-pressant properties, potentially comparable to medica-tions, in patients with CAD and individuals with depression in the general population.123 In terms of their impact on cardiac outcomes, a recent Cochrane Review found that psychological interventions likely have no effect on all-cause mortality(risk ratio, 0.81[95% CI, 0.39-1.69])and may have little to no effect on major adverse cardiac events(risk ratio, 1.22[95% CI, 0.77-1.92]; 4 studies,450 participants; low-certainty evidence).124

In our current internet-focused era, cognitive behav-ioral therapy has also been delivered online and evalu-ated in several randomized clinical trials. Both self-guided and therapist-guided interventions have shown posi-tive results. A meta-analysis of internet-based cognitive behavioral therapy in patients with cardiovascular dis-ease involving 8 randomized controlled trials and a total of 1117 patients found significantly reduced depressive and anxiety symptoms.125

Beyond single treatments, more comprehensive men-tal health care management programs that use a behav-ioral health care professional and consulting psychiatrist care for both ongoing symptom monitoring and stepped care for both depression and anxiety.126 These programs(with or without a component that also focuses on bio-logical factors) are linked to improvements in mental health, quality of life, and functioning among those with recent Ml or other acute cardiovascular conditions.127-130 In terms of the management of stress more broadly, sev-eral mind-body therapies appear to be effective, even in those without formal mood or anxiety disorders. Specifi-cally,mindfulness-based stress reduction,mindfulness meditation, yoga, and related treatments have been linked to reduced stress in those with cardiovascular dis-ease.131-136 Although this may be beyond the scope of what most health care professionals can address in a limited time frame, factors that may be contributing to stress and negative psychological health such as home,marital, and work environment44,137,138 can be discussed and considered.

One specific intervention that can provide a wide range of post-MI benefits is cardiac rehabilitation.PMPD is common among attendees of cardiac rehabilitation.139 In addition to its focus on exercise and effects on physi-cal cardiac recovery, cardiac rehabilitation programs typi-cally assess for depression and anxiety. Such programs can provide substantial mental health benefit themselves,including stress management education, and these ben-efits may be enhanced with adjunctive treatments such as cognitive behavioral therapy, mindfulness-based stress reduction, and dedicated stress management

training.70,140-142 Programs additionally often can make referrals to a behavioral health specialist when needed.For example, cardiac rehabilitation and exercise training programs have been shown to reduce depressive symp-toms, anxiety, hostility, and stress, and such reductions in these programs have been associated with improved cardiac outcome.70,140-145 Unfortunately, most post-MI patients do not attend cardiac rehabilitation,95 and this appears to be a potential“low-hanging fruit” by which patient prognosis can be improved and PMPD can be addressed.70,95,139-142

In clinical practice, when a cardiologist or general medical health care professional identifies PMPD, there are numerous potential options. The clinician can explain the connection between stress and cardiac health;encourage the use of social support(which is linked to superior cardiac outcomes)146; outline the benefits of exercise, healthy eating, and sleeping on both cardiac and mental health; and recommend wellness-based interventions(meditation, yoga) that can substantially reduce stress. Health care professional endorsements with referral to a cardiac rehabilitation program for nearly all post-MI patients are indicated,95 especially for those with depressed mood, anxiety, or stress.

If the clinician identifies that the patient has a more specific, formal diagnosis of depression, PTSD, or an anxiety disorder, initiating treatment with an SSRI(eg,serrineal starting at 50-75 mg/d) can provide benefit Clinicians whose health systems have access to options for evidence-based therapy(eg, cognitive behavioral therapy) or behavioral health care management programs(eg, collaborative care) can also make referrals to those programs. Integrating psychological care into cardiovas-cular care is also becoming more common 147,148 and can aid with clinical decision-making and more timely care for PMPD. Once treatment is initiated, symptoms can be serially monitored with the use of self-report mea-sures(eg, 9-item Patient Health Questionnaire, 7-item Generalized Anxiety Disorder) to assess improvements.If patients have more serious symptoms(eg, moderate to severe depression or suicidal thoughts), referral to outpatient psychiatry or psychology services is indicated,where a combination of drug therapy and psychotherapy may often be used.

ORGANIZATIONAL GUIDANCE ON PSYCHOLOGICAL SCREENING,RECOGNITION,AND TREATMENT

Major medical organizations are now including specific discussion of and often formal recommendations in their guidelines and organizational statements on ACSs and cardiac disease prevention. A 2021 American Heart As-sociation scientific statement concludes that the prepon-derance of data suggest that interventions to improve

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 Figure. Biologically plausible mechanisms by which MI leads to PMPD, which in turn leads to increased cardiac risk.

MI indicates myocardial infarction; PMPD, postmyocardial psychological distress; and PTSD, posttraumatic stress disorder.

$\boldsymbol{\text { psychological health can have a beneficial impact on car- }}$divascular health and that consideration of psychologi-cal health is advisable in the evaluation and management of patients with or at risk for cardiovascular disease.' The 2025 American College of Cardiology/American Heart Association/American College of Emergency Physi-cians/National Association of EMS Physicians/Society for Cardiovascular Angiography and Interventions guide-line for the management of patients with ACSs empha-sizes psychosocial considerations and psychological support such as open dialog about symptoms of depres-sion and anxiety as a core component of patient edu-cation and cardiac rehabilitation.30 The 2023 European Society of Cardiology ACS guideline recommends that all patients with ACS have their mental well-being assessed with validated tools before hospital discharge, with con-sideration of psychological referral when appropriate.31 The European Society of Cardiology guidelines on the prevention of cardiovascular disease state that patients with coronary heart disease and moderate to severe ma-jor depression should be considered for antidepressant treatment with an SSRI.32 Last, the American Association of Family Physicians recommends screening for depres-sion in patients with recent ACS.33

with increased risk of recurrent adverse cardiac events,and post-MI depression can reasonably be formally characterized as a cardiac risk factor, along the lines of more traditional cardiac risk factors such as hyper-tension and diabetes. Possible mechanisms by which MI may lead to PMPD include inflammation, avoidance,fear, withdrawal, and financial strain. Biologically plau-sible mechanisms by which PMPD may in turn lead to increased future cardiac risk include lesser physical activity, smoking(and failure to stop smoking), excess alcohol consumption, poor diet, obesity, inadequate sleep, inadequate social support, decreased medica-tion adherence, and poor attendance at cardiac reha-bilitation(Figure).

Whether post-MI patients should be formally screened for PMPD is unclear, but if a screen is conducted, then a process should be in place by which positive screens lead to more comprehensive assessment and treatment.At minimum, health care professionals should be aware of the high incidence of PMPD and be on the lookout for signs of depression, anxiety, psychosocial stress, and PTSD in their patients, both in the immediate in-hospital setting and during outpatient follow-up. Treatment options for PMPD include medications, comprehensive cardiac rehabilitation programs, cognitive behavioral ther-apy, and mindfulness-based stress reduction programs.Some data suggest that treatment for PMPD, particularly depression, may lead to decreased future cardiovascular events, particularly in those in whom treatment results in

SUMMARY

Up to half of post-MI patients may experience some form of psychological distress. PMPD is associated

CLINICAL STATEMENTS AND GUIDE

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Table 2. Sample Statements to Address PMPD in Clinical Encounters

|Sample statements to address depression| |---| |"It seems like feeling down or even a little hopeless about the future might be affecting the way you are taking care of yourself. Let's work together to figure out how we can fix this."| |Sample statements to address anxiety| |“It seems like your level of anxiety and worry is really wearing on you, and that can really affect your health and the way you take care of yourself. Let's think about how we can tackle this problem together."| |Sample statements to address stress| |"It seems like you are experiencing feeling a lot of stress related to(your health,finances,work,relationships),which can be common after heart problems.There are ways we can help. Can we talk more about this?"| |Sample statements about PTSD| |"After a heart attack, many people feel scared or worried about their health. Posttraumatic stress disorder(referred to as PTSD) is typical when someone goes through something very stressful or dangerous. You may have trouble sleeping, feel anxious, or avoid things that remind you of what happened. Would you like to talk to someone about this more?"|

PMPD indicates postmyocardial psychological distress.

Adapted with permission from Levine et al.' Copyright© 2021 American Heart Association, Inc.

a reduction of symptoms. Clearly, more high-quality, ide-ally randomized, clinical trials are desirable.

The data on whether effective treatment of PMPD improves cardiac prognosis are mixed and often less than optimal, and further studies, particularly in patients with anxiety, stress, and PTSD, would be helpful. Regard-less of whether interventions reduce future cardiovas-cular events, it behoves health care professionals to remind ourselves that we should not be hyperfocused on treating just cardiac disease but focused on treating the patient as a whole person.1 Multiple interventions can reduce psychological distress and thus lead to improved psychological health and a greater sense of emotional well-being.

Many health care professionals may not consider themselves experts in psychological health and may be reluctant to discuss psychological issues, something

they may consider“out of their lane.” Table 2 provides a few simple sentences that may put the patient at ease in sharing their feelings of depression, anxiety, or dis-tress. Some health care professionals may opt to use the quick, concise screening tool provided in Table 1;screening tools specific for stress such as the 4-item Perceived Stress Scale are readily available on the internet. Whatever the approach used to identify such possible symptoms, in those who seem to have PMPD,a gentle, nonjudgmental invitation to refer the patient to a mental health specialist will likely be welcomed by the patient and beneficial. A goal as health care profes-sionals should be to treat not only the disease but the person as a whole in front of us.

ARTICLE INFORMATION

The American Heart Association makes every effort to avoid any actual or poten-tial conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Spe-cifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on June 13, 2025, and the American Heart Association Executive Committee on July 21, 2025. A copy of the document is available at https://professional heart.org/statements by using either"Search for Guidelines& Statements" or the"Browse by Topic" area. To purchase additional reprints, call 215-356-2721 or email Meredith:Edelman@wolterskluwer.com

The American Heart Association requests that this document be cited as fol-lows: Levine GN,Carney RM,Cohen BE,Dunn SL, Gaffey AE, Kronish IM,Olsson Zheng, Huffman J, on behalf of the American Heart Association Stroke Council;Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology;Council on Quality of Care and Outcomes Research; and Council on Lifelong Congenital Heart Disease and Heart Health in the Young. Post-myocardial infarc-tion psychological distress: a scientific statement from the American Heart Asso-ciation. Circulation, 2025;152:e-e*. doi: 10.1161/CIR.000000000001381

The expert peer review of AHA-commissioned documents(eg, scientific statements, clinical practice guidelines, systematic reviews) is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit https://professional.heart.org/statements. Select the“Guide-lines& Statements* drop-down menu, then click“Publication Development”

Permissions: Multiple copies, modification, alteration, enhancement, and dis-tribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at https://www.heartorg/permissions. A link to the"Copyright Permissions Request Form" appears in the second paragraph(https://www.heart.org/en/about-us/statements-and-policies/copyright-request-form).

Disclosures

Writing Group Disclosures

|Writing group member|Employment|Research grant|Other research support|Speakers' bureau/ honoraria|Expert witness|Ownership interest|Consultant/advisory board|Other| |---|---|---|---|---|---|---|---|---| |Glenn N. Levine|Baylor College of Medicine/Cardiology|None|None|None|None|None|None|None| |Jeff C. Huffman|Massachusetts General Hospital|None|None|None|None|None|None|None| |Robert M. Carney|Washington University|None|None|None|None|None|None|None| |Beth E. Cohen|UCSF|None|None|None|None|None|None|None|

(Continued)

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CLINICAL STATEMENTS

Writing Group Disclosures Continued

|Writing group member|Employment|Research grant|Other research support|Speakers—bureau/ honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Susan L. Dunn|University of Illinois Chi-cago College of Nursing|NIH(DSMB)*|None|None|None|None|None|None| |Allison E. Gaffey|Yale School of Medi-cine; VA Connecticut Healthcare System|NIH/NHLBI (K23HL16823)+|None|None|None|None|None|None| |lan M. Kronish|Columbia University Irving Medical Center, Center for Behavioral Cardiovascular Health|NIH(received funding from NIH investigator- initiated grants that cover a portion of his salary)+|Springer/Current Cardiology Reports (section editor for the journal and gets a nominal stipend)*|None|None|None|None|None| |Erik M.G. Ols- son|Department of Women's and Children's Health, Clinical Psychology in Healthcare, Uppsala University(Sweden)|Swedish Research Council(research project grant)+|None|None|None|None|None|Uppsala University (professor[full- time employee 100%)]+|

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be"significant" if(a) the person receives$5000 or more during any 12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be"most of" if it is less than"significant" under the preceding definition.

*Modest.

+Significant.

Reviewer Disclosures

|Reviewer|Employment|Research grant|Other research support|Speakers' bureau/honoraria|Expert witness|Ownership interest|Consultant/ advisory board|Other| |---|---|---|---|---|---|---|---|---| |Carl J. Lavie Jr|Ochsner Medical Center|None|None|None|None|None|None|None| |Nicole Rosendale|University of California, San Francisco|None|None|American Academy of Neurology Annual Meeting speaking honorarium|None|None|None|None| |Alexandra L. Terril|University of Utah|None|None|None|None|None|None|None| |Tores Theorell|Stockholm University (Sweden)|None|None|None|None|None|None|None| |Lawson R. Wulsin|University of Cincinnati|None|None|None|None|None|None|None|

This table represents the relationships of reviewers that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Ques-$$\text{ I onnaire, which all reviewers are required to complete and submit. A relationship is considered to be"significant" if(a) the person receives$5000 or more during any}$$12-month period, or 5% or more of the person's gross income; or(b) the person owns 5% or more of the voting stock or share of the entity, or owns$5000 or more of the fair market value of the entity. A relationship is considered to be"mostest" if it is less than"significant" under the preceding definition.*Modest.

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