ASSESSMENT OF ANXIETY BEFORE SURGERY
IN CARDIAC SURGERY PATIENTS WHO HAVE NO HISTORY OF ANXIETY: SUPPORTING FACTORS AND
POSTOPERATIVE MORBIDITY
Yose Wizano, Dedy Kurnia
Fakultas
Kedokteran, Universitas andalas, RSUP Dr. M Djamil Padang, Indonesia
Email: wizano@kemkes.go.id, dedykurnia@med.unand.ac.id
|
KEYWORDS Preoperative Anxiety, Cardiac Surgery, Risk Factors,
Anxiety Levels |
ABSTRACT Anxiety is a
negative or threatening emotion that a person feels in general, in the long
term (anxiety trait), or in certain situations that fluctuates over time
(anxiety state). The research method used is a systematic review conducted by
looking for articles related to the assessment of factors supporting anxiety
before surgery in cardiac surgery patients who do not have a history of
postoperative anxiety and morbidity through an electronic database search,
namely ProQuest, and Google Scholar conducted in June – August 2022. RESULTS
AND DISCUSSION: Patients with preoperative heart surgery have a moderate-high
level of anxiety with many influencing risk factors. The extent to which each
patient manifests his or her preoperative anxiety depends on many factors
such as the patient's susceptibility to preoperative anxiety, age, gender,
past experience with surgery, educational status, type and degree of proposed
surgery, current health status, and socioeconomic status. .
Patients with high postoperative pain have high morbidity and mortality, poor
recovery, impaired wound healing, poor satisfaction, and longer hospital
stays. Conclusion: Based on the results of the study in this systematic
review, it was shown that patients undergoing cardiac surgery showed moderate
to high levels of preoperative anxiety, with little medical information
obtained, especially those related to surgery. Many factors influence the
emergence of anxiety in preoperative cardiac patients, including fear of
postoperative complications, lack of preoperative information to patients
about surgical methods and procedures and the anesthesia they will undergo,
not having strong social support, fear of death, fear of the unknown, the
danger of doctor or nurse error, the need for blood transfusions, and the
patient's comorbidities. Preoperative psychosocial factors are associated
with poor short-term and long-term outcomes after cardiac surgery, so the
detection and assessment of the patient's anxiety level before undergoing
cardiac surgery should be carried out to consider interventions aimed at
reducing anxiety in these patients. |
INTRODUCTION
Spielberger defines anxiety as a negative or threatening emotion that a
person feels in general, in the long term (anxiety traits), or in certain
situations that fluctuates over time (anxiety states). Anxiety in patients can
be caused by unusual situations, physical separation from family, no or little
knowledge of medical interventions, diagnoses, or therapeutic methods, high
operating costs, hospitalization, induction of anesthesia, postoperative pain,
possible future disability, and death (Fathi et al., 2014).
Anxiety, strong behavioral and psychological reactions, the patient's
perioperative experience is very severe and exacerbated by preoperative
concerns about the underlying disease, anesthesia and the surgery to be
performed. The prevalence of preoperative anxiety development ranges from 11%
to 80% in adult patients, and also varies among different surgical groups.
Various studies conducted on patients scheduled for heart disease surgery,
estimate preoperative anxiety as a major cardiovascular risk factor. This study
shows that preoperative anxiety can increase the occurrence of complications in
the immediate postoperative period, such as prolonged use of mechanical
ventilation, higher incidence of hemodynamic disturbances, increased
postoperative pain, analgesic consumption, increased anesthetic requirements,
and also lower hospital return rates. Higher (Hernández-Palazón et al., 2018).
High levels of preoperative anxiety are associated with altered
neuroendocrine responses, which may adversely affect the postoperative period.
A recent study demonstrated that anxiety is associated with increased
cardiovascular morbidity and mortality after coronary artery and valve surgery,
with anxiety as an independent predictor of cardiovascular postoperative
outcome (Hernández-Palazón et al., 2018). Previously, we demonstrated that patients with high
preoperative anxiety had a higher mortality rate. significantly high four years
after surgery. People who are socially isolated (eg,
those who are single or have a small social circle) are at higher risk for
morbidity and mortality according to recent research. Morbidity and mortality
associated with myocardial infarction increase with the severity of symptoms of
depression and anxiety, especially in patients with low educational and social
support status.
In the preoperative period, patients awaiting cardiac surgery at that
time may experience high levels of anxiety and depressive symptoms followed by
impaired functional status, chest pain, shortness of breath due to worry, fear,
and outcome of surgery. Symptoms of anxiety, stress, depression, and pain are
disorders that commonly occur in coronary heart disease patients, including
those undergoing coronary artery bypass surgery therapy. All of these factors
exacerbate existing disease symptoms, adversely affect physiological parameters
before and during anesthesia, can lead to a long recovery and impair quality of
life after surgery.
Anxiety causes hypertension, increased heart rate, and may lead to
bleeding and other possible postoperative side effects. On the other hand,
long-term anxiety increases metabolism, oxygen consumption, and emotional
conception of pain
To improve the patient's overall perioperative experience,
anesthesiologists often administer preoperative anxiolytic drugs to calm
patients before they enter the operating room. However, it has recently been
shown that preoperative sedation with lorazepam compared with placebo or no premedication
in patients scheduled for non-cardiac surgery does not improve the
perioperative experience or overall patient satisfaction with daily
postoperative days, but is associated with a longer time to extubation.
and lower rates of early cognitive recovery. Therefore, it is necessary to
evaluate or measure anxiety in patients who have scheduled cardiac surgery to
identify factors that can contribute significantly to preoperative anxiety in
order to get proper control.
Worry
According to the American Psychological Association
(APA) Anxiety is defined as a feeling of tension, fear, nervousness, worry,
discomfort, and high autonomic activity with varying degrees of intensity
resulting from the anticipation of danger or threatening events or something unknown,
which can affect physiological responses. The clinical manifestations of
anxiety are irritability, isolation, nervousness, insecurity, feelings of
uncontrollable worry, difficulty concentrating, difficulty sleeping, headaches,
sweating, tingling, tachypnea, tachycardia, and hypertension. Cognitive
disorders such as impaired thinking, decision making, perception, and
concentration are also a consequence of anxiety
The prevalence of preoperative anxiety in the
western population was reported in one study to range from 12.6-76.7% in the
western population (Kuzminskaitė, Kaklauskaitė,
& Petkevičiūtė, 2019), while in Ethiopia it was recorded to range from
39.8-70.3%. produce various neuro-endocrine changes (eg release of catecholamines) in the body. This
process ultimately causes an increase in heart rate, blood pressure, and the
workload of the heart muscle. Excessive hemodynamic response related to
electrocardiographic changes in patients with preexisting chronic hypertension
Cardiac surgery
The World Health Organization (WHO) shows that 17.8
million people died from cardiovascular disease or also known as Cardiovascular Disease (CVD) in 2017, and the global death
rate reached 31%. In 2016, CVD caused more than 17.9 million deaths with a
global mortality rate of around 31.0%. Furthermore, 85% of these deaths are from
CVD (ie, heart attacks and strokes). In addition, it
was reported that 56.7% of patients aged 65 years had received Coronary Artery
Bypass Graft (CABG); this number is ultimately projected to increase to 67.3%.
The total cost for CABG patients is over $30,000. Therefore, the cost of
medical care is significant for patients undergoing CABG (Yuenyongchaiwat, Buranapuntalug,
Pongpanit, Kulchanarat, & Satdhabudha, 2020).
An estimated 2 million heart surgeries are performed
worldwide each year (Fuhrman & Kellum, 2017).
In general, patients require cardiac surgery because they have unbearable
angina from coronary heart disease or severe dyspnea due to valvular heart
disease. It is possible that the more severe the patient's disease, the worse
the preoperative symptoms, and the less the patient can perform daily
activities. Therefore, the severity of these symptoms will lead to the
emergence of anxiety to depression.
METHOD RESEARCH
The
research method used is a systematic review conducted by looking for articles
related to the assessment of anxiety supporting factors before surgery in
cardiac surgery patients who do not have a history of postoperative anxiety and
morbidity. The literature search was carried out in June – August 2022 through
electronic database searches, namely ProQuest, and Google Scholar.
The next
international journal search was carried out by researchers through ProQuest
with the keyword "Patients Anxiety of Preoperative Cardiac Surgery with No
History of Anxiety" and the search year was limited from 2012 to 2022. The
search for national journals was carried out through Google Scholar with the
keywords "Patient Anxiety". prior to cardiac surgery with no history
of anxiety” and the year search was limited from 2012 to 2022.
The
journals and articles obtained were then filtered by title and abstract. The
articles selected by the researchers were based on the desired criteria, namely
anxiety in patients before heart surgery who did not have a history of anxiety.
Meanwhile, journals that are not relevant to the research topic are excluded.
The selected journals were evaluated using the inclusion and exclusion criteria
of the study, based on the sorting of these criteria, appropriate journals were
obtained for systematic review. The inclusion criteria used in the systematic
review were journals published from 2022 to 2022, patients who will undergo
cardiac surgery, before surgery, patients without a previous history of
anxiety, English articles and the results obtained by the patient's level of
anxiety.
The results
of the Literature Search found 2,630 articles on ProQuest and Google Scholar
data. Selecting the title and abstract of the article, then we got 1,537
articles. From this assessment, 1,518 articles were issued. There are 19
articles with complete manuscripts remaining. Of the nineteen articles, 9
articles were found that were suitable for systematic review.
RESULTS AND DISCUSSION
Factors
influencing anxiety in patients before cardiac surgery
Surgery is a
stressful event with physiological reactions in the body such as an increase in
heart rate, breathing, blood pressure and other risk factors. In addition,
psychological conditions and mental stress can affect physical illness and
accelerate its worsening. The emergence of stress in patients occurs in several
stages from diagnosis to recovery such as decision making for surgery, hospital
selection, spending money, and postoperative care. Besides they face social
pressures, they also face mental and physical pressures. In fact, the
perception and acceptance of surgery as a medical treatment of last resort is
shocking and affects all physical and mental aspects of their lives. Fear of
death and tolerance of the consequences of surgery prompted them to avoid
surgery, but because of the pain and difficulty breathing, they felt compelled
to accept heart surgery. Hopelessness and disappointment arise with feelings of
inadequacy and lack of interest in life and the patient becomes much inactive
because of his hopelessness. Some patients, after being advised to perform
surgery, are generally unable to realize their condition and do not make the
right decisions (Mahdavi, Esmaeili, Heidari-Gorji,
Mohammadi-Tazeh, & Cherati, 2016).
The extent to which
each patient manifests his or her preoperative anxiety depends on many factors
such as the patient's susceptibility to preoperative anxiety, age, gender, past
experience with surgery, educational status, type and degree of proposed
surgery, current health status, and socioeconomic status. Research conducted by
Mulugeta et al. found that the most common factor
responsible for preoperative anxiety was fear of postoperative complications
Evidence and
documents show that psychological conditions cause changes in the body's immune
system and cause disease in humans. Behavioral factors can change the level of
susceptibility and suffering of disease through the function of the endocrine
glands. Benson War, believes that high levels of hope are associated with
physical, psychological health, high self-esteem, positive thinking, and good
social relationships. Snider concluded in a study that low levels of hope
predict the appearance of depressive symptoms. Jackson et al, concluded that
expectations have a direct relationship with fitness or adjustment functions
such as psychological fit, physical health and problem-solving skills.
Research conducted by
Heshmati R et al, shows that spiritual well-being and
hope can be important factors in determining the health level of anxiety for
adults with coronary artery disease, and this deserves further exploration to
help reduce anxiety levels for patients with coronary artery disease (Heshmati, Jafari, Salimi Kandeh, &
Caltabiano, 2021).
Mahdavi A et al said that
patients undergoing open heart surgery have tolerated and experienced a lot of
anxiety and have a low life expectancy, therefore, they need more
easy-to-understand information followed by social and family support.12Fathi M et
al dalam penelitiannya mengungkapkan bahwa wanita mengalami lebih banyak kecemasan
daripada pria. Hal ini sejalan dengan penelitian Muguleta et al yang mengatakan bahwa perbedaan tingkat kecemasan pada wanita lebih signifikan dibandingkan pria karena wanita sensitif
terhadap kejadian menakutkan dan perbedaan fluktuasi hormon. Selain itu, wanita
lebih mudah mengekspresikan kecemasan mereka daripada pria, dan perpisahan dari keluarga lebih
mempengaruhi wanita.
Higher income levels
and better social support can reduce anxiety levels. In addition, Fathi et al also found that patients with higher education
levels, agricultural workers, self-employed, married or single patients had
significantly lower levels of preoperative anxiety. A good doctor-patient
relationship with the anesthesiologist can reduce anxiety levels.1 Previous
studies have shown that explaining preoperative information to patients about
the surgical and anesthetic methods and procedures they will undergo will
reduce patient anxiety (Mulugeta, Ayana, Sintayehu, Dessie, &
Zewdu, 2018). Comorbidities and underlying diseases, and addictions
also associated with anxiety levels.
Research by Bedaso A, et al found that not having strong social
support, unexpected surgical outcomes, danger from doctor or nurse error, need
for blood transfusion, and not being able to recover were found to be
statistically significant for preoperative anxiety. Patients need to be
assessed regularly for anxiety during the preoperative visit (Bedaso & Ayalew, 2019). in conjunction with the study of Wondmieneh
A et al also found that fear of death, fear of the unknown, and fear of
postoperative complications were significant predictors of the emergence of
preoperative anxiety (Wondmieneh, 2020).
Effect
of anxiety on postoperative cardiovascular morbidity
Several recent
studies have investigated the relationship between preoperative anxiety and
morbidity/mortality rates. These studies suggest that preoperative anxiety is
an independent predictor of postoperative morbidity and mortality including
late death using survival analysis. Anxiety-related morbidity and mortality are
more significant in elderly patients and cardiac patients (Almalki, Hakami, & Al-Amri, 2017).
Several studies have
shown that psychological factors such as anxiety and fear can influence an
individual's response to surgical intervention and postoperative pain
management. Patients with high postoperative pain have high morbidity and
mortality, poor recovery, impaired wound healing, poor satisfaction, and a
longer hospital stay (Tadesse et al., 2022). Research
conducted by Kashif M et al revealed that patients with moderate anxiety levels
to severe preoperative cardiac surgery experienced significantly higher pain
scores in the postoperative period than the group with mild anxiety levels.
Intraoperative and postoperative analgesic requirements also increased
significantly (Kashif, Hamid, & Raza, 2022).
Preoperative
psychosocial factors are associated with short- and long-term outcomes after
cardiac surgery. There are several approaches to optimizing the patient's
psychological status before surgery with promising effects on postoperative
outcomes (eg, fewer complications, improved quality
of life). Preoperative psychological preparation often aims to increase the
patient's knowledge or social support and to modify and optimize disease
expectations and beliefs. The term "psychological preparation" is not
clearly defined. From our perspective, this includes a variety of techniques
for changing cognition, emotion, or behavior. Types of preoperative
psychological interventions that are useful for surgical patients such as
providing procedural information (information about the process that describes
what, when and how the surgery will take place), sensory information (describes
what it will feel like), behavioral instructions (information about what will
happen). what the patient should do such as when the patient should return to
usual activities), cognitive interventions (aimed at changing the way the
patient thinks about surgery; may include developing different perspectives and
distractions), relaxation techniques (systematic instruction of physical and
cognitive strategies to promote relaxation and feelings of calm), hypnosis and
emotion-focused interventions (aimed at enabling the patient to regulate and
manage emotions such as understanding and accepting emotions).
Mihalj M et al. revealed in his research that a comprehensive
preoperative assessment for evaluation of the patient's condition before
undergoing cardiac surgery and joint decision making between the patient,
surgeon and anesthesiologist before surgery regarding the risks, benefits,
treatment goals, values and expectations can improve
postoperative outcomes. In joint decision making, all treatment options,
scientific evidence, and the patient's health care goals should be discussed in
a multidisciplinary manner before starting treatment. Ideally, this discussion
occurs early in treatment, initiated by the patient's primary physician or
cardiologist, followed by the involvement of the cardiac surgeon and
anesthesiologist. Medical treatment options and interventions as well as the
pros and cons of each expert need to be discussed. Health care providers need
to understand the patient's current physical and mental condition, overall
prognosis, expectations about treatment, and short- and long-term goals. Shared
decision making is a multidisciplinary approach in which physicians and
patients discuss the available evidence about clinical care, while patients are
supported to make informed decisions about their care, so that an informed
preference can be reached (Mihalj, Carrel, Urman, Stueber, &
Luedi, 2020).
CONCLUSION
Based on the results of the study in this systematic review, it
showed that patients undergoing cardiac surgery showed moderate to high levels
of preoperative anxiety, with little medical information obtained, especially
those related to surgery. Many factors influence the emergence of anxiety in preoperative
cardiac patients, including fear of postoperative complications, lack of
preoperative information to patients about surgical methods and procedures and
the anesthesia they will undergo, not having strong social support, fear of
death, fear of the unknown, the danger of doctor or nurse error, the need for
blood transfusions, and the patient's comorbidities.
Anxiety is a temporary emotional state that arises in patients who
are about to undergo cardiac surgery procedures. Preoperative psychosocial
factors are associated with poor short-term and long-term outcomes after
cardiac surgery, so the detection and assessment of the patient's anxiety level
before undergoing cardiac surgery should be carried out to consider
interventions aimed at reducing anxiety in these patients.
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Copyright holders:
Yose Wizano,
Dedy Kurnia (2022)
First publication right:
Devotion - Journal of Research and Community
Service
This article is licensed under a Creative Commons Attribution-ShareAlike 4.0 International