ABSTRACT

Aim: This dissertation is an extended review of literature that aims to determine the experiences of UK patients that survive myocardial infarctions beyond thirty days.

Background: Cardiovascular disease remains a significant public health burden in the United Kingdom. According to the British Heart Foundation (2020), seven out of every ten patients that experienced a myocardial infarction in the 1960s died, but at present, seven of every ten sufferers survive the event. However, despite the high survival rate of MIs in recent decades, there has been little focus on the experiences of survivors compared to mitigation and prevention.

Focus Question: What are The Psychological Experiences of Patients Post-Myocardial Infarction?

Methodology: Several databases were searched systematically, and a selection of keywords used to identify relevant research. Analysis of titles and abstracts identified over twenty articles. A rigorous inclusion and exclusion criterion was used to identify the ten most relevant literature. A mixed-methods approach that also involved a framework approach to thematic analysis was used to identify relevant themes that defined the post-MI experience of patients.

Results: The post-MI experience for patients in the UK setting is overwhelmingly negative. The experience is characterised by constant fear and anxiety, a higher likelihood of depression, unusual fatigue, diminished quality of life, a poor understanding of illness and symptoms, and a negative outlook on life.

Conclusion:  Nurses and other healthcare workers need to understand the post-MI experience of patients better to enable targeted evidence-based approaches to improve the experience. Special consideration should be given to ethnic minority experiences and the experiences of younger survivors (<55) of myocardial infarctions.

What Are The Psychological Experiences Of Patients Post-Myocardial Infarction?

INTRODUCTION

Overview

Myocardial infarction is often a dramatic near-death experience for most patients that survive and often results in significant life changes for survivors. It results from the occlusion of the coronary artery or its associated blood vessels, causing ischemic injury to the heart muscle.  At its most dramatic, patients have described a crushing force akin to having a truck standing on one’s chest with an acute awareness of one’s heartbeat, chest pain that radiates to the right arm, neck or jaw and a sense of impending doom that causes significant emotional distress and anxiety (McKee et al., 2018). While symptoms can often be milder and atypical, especially for women or elderly individuals, the realisation that one has suffered a myocardial infarction is often startling. It brings a person’s mortality into sharp focus (McKee et al., 2018). In the aftermath of an MI, patients are often expected to be grateful for surviving. Still, the event often results in significant life changes and long-term symptoms of a myocardial disease that can cause psychological challenges and a diminished quality of life. Despite this fact, there remains little focus on the post-event experience of survivors of myocardial infarctions even though survival rates have increased considerably in recent decades. This extended review of the existing literature will use both qualitative and quantitative primary sources to build a detailed picture of the post-myocardial infarction experience of patients.

This extended literature review will consist of several sections. The next section after this introductory section will be the background and rationale section. The background and rationale section will provide the theoretical basis for the topic and address why the topic is important to nursing. The methods section will provide a comprehensive analysis of how the research was undertaken and the basis for the selection of core evidence used. The findings section will present the results of the literature review. Each of the selected papers will be critically presented, and important themes that cut across the different papers will be analysed in-depth.

The discussion section will offer a critical analysis of the findings from the perspective of the researcher. A brief overview of the strengths and limitations of the extended literature review will be conducted before the conclusion. The conclusion will summarise the important aspects of the paper. This extended review of the existing literature will use both qualitative and quantitative primary sources to build a comprehensive picture of the post-myocardial infarction experience of patients.

BACKGROUND AND RATIONALE

Background

Cardiovascular disease remains a significant public health burden in the United Kingdom. Cardiovascular disease can be defined as pathological conditions that involve the circulatory system and associated organs (Denmark et al., 2019; Reed, Rossi and Cannon, 2017). National Health Service (NHS) (2020) and the British Heart Foundation (BHF) (2020) report that cardiovascular disease is responsible for more than 25% of all deaths within the UK every year. On average, over 450 people die each day due to cardiovascular disease (BHF, 2020). The problem remains a significant burden despite significant funding for research into prevention and mitigation. Unfortunately, the mitigation aspect has been  more successful than the prevention aspect of cardiovascular disease.

While the situation is not wholly negative as more people survive severe cardiovascular events more than ever before, the number of people living with significant cardiovascular disease in the UK has risen sharply in recent decades. BHF (2020) notes that over 7.4 million people are living with significant cardiovascular disease in the UK presently. A myocardial infarction (MI) is one of the most dramatic and severe presentations of cardiovascular disease (Reed, Rossi, and Cannon, 2017). Myocardial infarction is often a complication of coronary heart disease. Colloquially referred to as a heart attack, MIs are most commonly caused by the blockage of the coronary artery and associated blood vessels by a blood clot or atherosclerotic plaque resulting in ischaemic injury or death of myocardial cells (Denmark et al., 2019; Reed, Rossi and Cannon, 2017). Advances in healthcare have significantly reduced the mortality rate of MIs in western nations.

An MI is often a near-death experience that causes significant emotional distress for those experiencing it, especially for those who were unaware of any underlying issues (Thomson et al., 2013; Lewis et al., 2014; Iles‐Smith et al., 2017). The significant risk of mortality often means that survivors are expected to be grateful. However, the aftermath of myocardial infarction is often a time of substantial psychological turmoil and uncertainty as sufferers try to come to terms with what happened. Often, patients are acutely aware that the risk of death remains high following the event resulting in anxiety and uncertainty (Galdas et al., 2010; Hawkes et al., 2013).

The difficulty in controlling symptoms (which patients can often mistake as another severe cardiac event), significant morbidity and disability, and the necessity of crucial lifestyle changes often make the post-MI experience difficult for patients (Walters et al.; 2014; Merritt et al., 2017). However, despite the high survival rate of MIs in recent decades, there has been little focus on the experiences of survivors compared to mitigation and prevention.

Rationale

According to the British Heart Foundation (2020), seven out of every ten patients that experienced a myocardial infarction in the 1960s did not survive the event. The organisation notes that advances in healthcare mean that at present, seven of every ten patients that experience a heart attack survive the event. The higher survival rate means that prospective nurses are more likely than ever to manage or interact with patients that have survived an MI in the short or long-term. Such patients are often in the midst of psychological turmoil due to the dramatic experience that constitutes myocardial infarction, the prospect of a shortened life, loss of income and capacity to provide for themselves or their loved ones, disability, loss of personal autonomy, and persistent symptoms (Galdas et al., 2010; Kendall et al., 2014; Hawkes et al., 2013; Lewis et al., 2014; Walters et al.; 2014; Merritt et al., 2017). Often, such patients are aware that healthcare workers may obscure information to keep their spirits up and focused on recovery (Sampson et al., 2010). In the age of the Internet of Things, patients may also seek information from alternative sources and focus on prognosis with a bias towards poor outcomes, which can increase the mental health strain.

With nurses increasingly likely to face such complex situations, it would be prudent for them to be well prepared. A well-prepared nurse would know what to expect in such situations and how to ensure that the patient receives not only high-quality healthcare but also emotional support at such a difficult time of their lives. The knowledge may also help nursing leaders formulate evidence-based guidelines for cardiac rehabilitation following myocardial infarction (Galdas et al., 2010). Evidence-based guidelines would fit with the times as healthcare is increasingly being tailored based on the best available evidence.

METHODOLOGY

Overview

This section of the extended literature review will critically analyse the literature chosen for this review as well as the basis for the selection of research material. As Hart (2018) notes, an extended literature review does not merely offer the findings of the researcher. The review offers a detailed basis for nearly all decisions that the reviewer makes in the process of the review to ensure those using the information can critically analyse the decisions as well. Ridley (2012) agrees with this take on extended literature reviews and notes that the methodology section provides the chance to present a detailed basis for the selection of the evidence used in the analysis. Ridley (2012), Hart (2018), Walters et al. (2014) and, Merritt et al. (2017) all agree that evidence-based practice is central to modern healthcare. Ridley (2012) and Hart (2018) further contend that a clear review of the methodology in an extensive literature review would allow other researchers and utilisers of the research to find gaps in the available literature.

Development of Focus Question

There are several frameworks available for developing a focus question. The frameworks for the development of the focus question are important to avoid the trap of a focus that is too broad (Doody and Bailey, 2016). A broad question is problematic because of the availability of too much information for researchers. Specificity is key in developing the question. The most common frameworks include SPIDER, FINER, PICO, and PEO, among others (Doody and Bailey, 2016).

P	Patient
E	Myocardial infarction
O	Psychological Experience

Table 1: Development of focus question using PEO framework.

Table one shows the PEO framework method for developing a focus question. All the frameworks mentioned above were considered for the development of the paper’s focus question. Ultimately, it was decided that the PEO framework was the best for this case, as it is simple and appropriate for qualitative research questions (Doody and Bailey, 2016).

Literature Search

Primary Search Strategy

Structured scientific research on most subjects is extensive, with research on some topics stretching several centuries back. The wide availability of information can make a focused analysis of existing difficulties, as researchers may find that there is too much information. In recent decades, attempts have been made across the globe to put nearly all research material online to make it easily accessible across the world and to reduce redundancies. While positive, the move has resulted in a considerable amount of research material existing online. Onwuegbuzie and Frels (2016) and Torraco (2016) both agree that the vast amount of information can make finding the right correct evidence for a concise literature review difficult. Ridley (2012), Onwuegbuzie and Frels (2016), Torraco (2016), and Hart (2018) all concur with the need to develop an effective literature search strategy that includes only the most relevant evidence.

For this research, a search of several relevant databases was conducted. Unfortunately, only online sources could be utilised for this research paper because of the restriction of movement order currently in place due to the SARS-Coronavirus 2 global pandemic (Wood et al., 2020). Several databases were used because using different databases offers a variety of information. Databases that were used for this paper include the British Nursing Index Database, CINAHL Plus database, NCBI database, PubMed database. Initially, searches in each database were attempted, but this proved cumbersome and provided minimal results. A decision was taken to use search engines that searched several databases simultaneously. Three search engines were used for this research: the Ovid emcare search engine, the nursing engine search engine, and the Google Scholar search engine.

The three search engines were deemed appropriate because they provide access to a very wide array of searches while also allowing a wide array of advanced search metrics that allowed the inclusion and exclusion criteria to be applied effectively (Cals and Kotz, 2016). Ovid, EmCare, and Google Scholar engines produced the best results and over 90% of the evidence used for this research. The search strategy relied heavily on the use of keywords and associated phrases. Advanced search metrics were altered several times to ensure a variety of evidence was found. Thesaurus function was also used to find words that are used instead of the keywords or used in close association with the keywords that may be of relevance to researchers.

Other Search Strategy

There were additional search strategies used to ensure that as much relevant evidence as possible was assembled. One important strategy was Snowballing. This strategy involves the use of references cited by a highly relevant study to find related studies (Wohlin, 2016). Researchers often rely on existing literature to formulate their studies, and this proved an effective strategy. While secondary sources were deemed inappropriate for this study, the references used by secondary sources that reported exclusively on primary sources were useful. Where the references did not include links, the title and name of the authors indicated in the reference were fed into the search engines to find the primary studies and review them for relevance.

Another strategy involved contacting authors of studies via email where contact details are provided. Unfortunately, on all occasions, this strategy was used, either no response was available at the time of preparing the literature review, or the studies where a response was received were deemed inappropriate for this review. While clinical anecdotes and case studies were deemed inappropriate for this review, systematic NHS evidence was viewed as acceptable, and an attempt was made to find evidence on this basis. This strategy was abandoned because it involved contacting the NHS repeatedly for information on the appropriateness of evidence found. Contacting the NHS repeatedly at a time of a national health crisis that placed a significant burden on the organisation was deemed to be inappropriate.

Counter-checking studies found in one database or search engine in other databases or search engines were also utilised to give reassurance that studies were considered appropriate by multiple sources. This strategy proved effective, as all studies selected for this research were found in more than one database. The finding offered researchers some surety that the evidence provided by the studies is valid and appropriate for use.

Keywords

Ridley (2012), Onwuegbuzie and Frels (2016), Torraco (2016), and Hart (2018) all agree that keywords are crucial for any research, including an extensive literature review. Torraco (2016) notes that in primary research material put online, keywords are essential because they help other researchers find the research paper when they type in the keywords into a search engine. Hart (2018) concurs and adds that for literature reviews, keywords are also important because they help the researcher find the relevant evidence to use in their review. The keywords are typed into the relevant databases. The main keywords identified for this extended literature review include: “post-myocardial infarction”, “patient experience”, “mental health”, “quality of life”, “cardiovascular disease”, “heart attack”, and “heart disease”.

These words presented either the exact wording that described the researcher’s title and area of focus or words that were frequently interchanged with these words and are referred to in the paper. Thesaurus, an online dictionary that provides synonyms or words that are often used in other words stead due to close approximation, was used to confirm the keywords from those used in the title as well as providing words that were used to refine searches. Other words that were used together with the keywords to refine searches include ‘ethnic experience’, ‘qualitative’, ‘quantitative’, ‘symptoms’, ‘anxiety’, ‘UK’, ‘United Kingdom’, ‘uncertainty’, and ‘angina’, among others. Boolean operators were also identified and used to link keywords and other search terms. “And”, “of” and “in” were the most consistently used Boolean operators for this review.

Advanced search metrics on the search engines were utilised to ensure that the keywords took prominence over the words that were used to refine searches. For instance, since a key tenet of the search was that the central evidence selected only be sourced from within the UK, one refinement metric involved ensuring only articles that mention “the UK” or “United Kingdom” specifically showed up on searches. This metric was utilised because it carved out American studies, which tend to crowd out UK studies.  Figure one below shows the use of advanced search strategy in obtaining the articles for review.

Figure 1: Screen Grab of the search strategy in use.

Inclusion and Exclusion Criteria

Torraco (2016) and Hart (2018) argue that setting the right inclusion and exclusion criteria is among the most crucial aspects of a literature review. The inclusion and exclusion criteria ensure that only the most relevant evidence that meets the researcher’s objectives and provides the best evidence to readers is selected. Hart (2018) insists that the criterion selected by researchers must be appropriate, clear, and justifiable to users of the material. The research used various inclusion and exclusion metrics to gather the required sources.

Inclusion Criteria

The year of publication was a key selection metric. The original intention for this metric had been to include only studies that were conducted within the last five, but finding primary research material based in the UK alone that fits this metric proved difficult. As a result, a decision was taken to extend the timeframe and only use research published within the last ten years. This inclusion metric was utilised to ensure that only the most recent and up to date data was presented since the management of myocardial infarction patients has changed significantly over the last six decades. Another important metric was geographical: only studies conducted within the United Kingdom were utilised. This decision was reached to ensure that the evidence provided is focused on nursing in the UK since UK nurses are the primary target of this review.

The use of English as the publishing language was also an important inclusion criterion. Other key inclusion criteria include the inclusion of primary researches only and peer-reviewed articles only. Primary research as an inclusion criterion ensures that the evidence used is not second hand while the inclusion of peer-reviewed material only ensures that the material used is factual.

Inclusion Criterion	Rationale
Year of Publication: 2010-present day	An attempt was made to use studies within the last five years as these are generally deemed to constitute the most recent literature. However, a deficit of research on the subject in that timeframe that met the other selected criteria forced an extension of the timeframe to ten years.
Geography: UK-based studies only	The target audience is nurses and healthcare workers within the UK; hence a local context was deemed essential.
Language: Only studies published in English	English is the researcher’s primary language, and the inclusion of studies published in English only enables an in-depth analysis.
Type of Research: Primary Research only; both qualitative and quantitative	The use of primary research ensured that only first-hand information that is factual and not clouded by the opinion of a secondary source is included
Accuracy and Validity: Peer-reviewed studies only	Peer-reviewed studies are analysed by experts before publication ensuring their validity and accuracy.

Table 2: Inclusion criteria and rationale

Table two shows the inclusion criteria as well as the rationale behind the decision to include the criteria.

Exclusion Criteria

Exclusion Criterion	Rationale
Year of Publication: Before 2010	Literature published before 2010 was deemed too old to be relevant in the present context due to advances in healthcare over the last ten years.
Geography: non-UK studies	Studies done in the US tend to crowd out those done in the UK and do not provide a local context for practice in the UK due to differences in healthcare policies. Overall, a local context was deemed to be crucial.
Validity and Accuracy: News articles, opinion pieces, clinical anecdotes and	While these types of material increase knowledge and spread information, they are too shallow, too narrowly-focused, or may contain inaccurate information and opinions rather than facts.
Language: Studies published in other languages.	The translation is impractical because it would be costly and time-consuming.
Type of Research: Secondary Research	The quick overview provided by secondary sources may be too shallow or contain biases and inaccuracies introduced by the researchers who assembled material.

Table 3: Exclusion criteria and rationale

Table three shows the inclusion criteria as well as the rationale behind the decision to include the criteria.

prisma

Research records identified through database search n=  16096

Research identified through other sources n= 0

Records after duplication is removed n= 4487

Records screened on basis of title and abstract n= 103

Full text article assessed for eligibility n= 20

Article included in final review n= 10

identification

screening

eligibility

included

 

Outcomes of Search

Search Term	Refinement	British Nursing Index Database	CINAHL	PubMed	NCBI
post-myocardial infarction		3,245	14,267	22,375	18,609
patient experience		66,403	99,789	105,778	102,308
mental health		89,408	111,607	124,656	114,665
quality of life		102,498	128,664	140,775	126,667
cardiovascular disease		124,300	134,600	135,776	132,775
	Combination of all terms	887	2,667	7,643	4,899
	In UK	361	537	1,004	883
	After 2010	67	103	447	119
	Ethnic Experience	8	13	21	23
Initial Articles Identified		3	7	14	15
Valid Articles Selected		1	2	3	4

Table 4: Outcomes of Database Searches

Table four shows the outcomes of the searches on the different databases.

Literature Review and Thematic Analysis

The literature search strategy is important in identifying the appropriate literature that meets the inclusion and exclusion criteria. During the search, only summaries and abstracts were used to identify studies that appeared to meet all the relevant criteria for this review. Twenty studies were identified by the search strategy as potentially highly relevant to this extended literature review. Only between 6-10 of the most appropriate literature in the time frame are needed for this review. Onwuegbuzie and Frels (2016) argue that where a review focuses on a specific number of studies in a given time frame rather than all studies in that time frame, it is essential to pick the most valid and appropriate studies. In this case, while both qualitative and quantitative literature were deemed acceptable, it was viewed as more appropriate to have more qualitative studies than quantitative. Qualitative studies are more suitable for capturing experience, which can be a highly subjective measure and difficult to standardise.

Berkman et al. (2015) argue that it is important to grade the strength of any body of evidence before considering it as a basis for evidence-based practice. Berkman et al. (2015) further identify limitations, directness, consistency, precision, and bias reporting as among the most important tenets of grading the strength of evidence for evidence-based practice. These grading metrics were utilised to whittle down the material from twenty to seven.

Mixed Methods Systematic Review

Mixed methods systematic review is increasingly becoming an important part of healthcare research (McKim, 2017). Mixed methods research is deemed to be superior to single method studies because it incorporates both aspects of both qualitative and quantitative studies (Venkatesh, Brown and Sullivan, 2016). Quantitative studies have often been seen as stronger and more valid than qualitative ones. However, in recent years, there has been an acknowledgment that patient experience of healthcare interventions is also a key tenet of its efficacy. For instance, quantitative studies have shown that using maggots in larval wound debridement is effective compared to existing therapies (Cazander et al., 2013; Cowan et al., 2013). However, qualitative studies have shown that patient disgust at maggots is considerable enough to exclude therapy as an option for most patients (McCaughan et al., 2015). In such a case, mixed-method research would provide a better picture as to the efficacy of the treatment option. This review used a mixed-method approach because it provides a superior picture of the existing evidence.

Thematic Analysis

Thematic analysis is one of the key ways of interpreting data in the qualitative research setting (Javadi and Zarea, 2016; Maguire and Delahunt, 2017; Castleberry and Nolen, 2018). It is used to identify patterns of meaning in qualitative data and is viewed as a method of analysing data rather than an approach (Terry et al., 2017). Javadi and Zarea (2016) state that thematic analysis is most often used to create coherent answers with research value from a person’s life experiences, behaviour, and perspectives on a given subject. Maguire and Delahunt (2017) note that there are several approaches to a thematic review currently available.

Clarke, Braun, and Hayfield (2015) identify six phases of a thematic analysis: familiarisation with data, code generation, generation of initial themes, review of themes, the definition of the themes, and reporting the themes. However, as Javadi and Zarea (2016) point out, a key tenet of thematic analyses is flexibility. This aspect of thematic analysis is acknowledged by Clarke, Braun, and Hayfield (2015), which offers three broad approaches that are differentiated by tweaks in the phases of analysis. The three approaches acknowledged by Clarke, Braun, and Hayfield (2015) are the code reliability approaches, the codebook

approaches, and the reflexive approaches. For this review, the framework analysis, an example of the codebook approach, will be utilised.

Figure 2: Steps of framework analysis.

Figure two above shows the steps of the framework analysis employed in the review. Nowell et al. (2017) identify the five phases of a framework analysis as familiarisation, indexing, charting, mapping, and interpretation. These steps formed the basis for the deciphering of the themes.

FINDINGS

Overview

A summary of the ten studies that form the core evidence for this extended literature review can be found in the appendix section. This section of the review will instead focus on the thematic findings of the mixed methods review and thematic analysis. Wu et al. (2016) note that, ultimately, the results of a study are the most crucial part of the study. The outcomes found to form the basis of the research, and they must be presented coherently. National Academies of Sciences, Engineering, and Medicine (2017) argues that the major purpose of the outcomes section is the provision of broken-down data sets that are arranged in such a way as to be relevant to the research question. The results section is supposed to offer the key findings without interpretation to prevent bias from being introduced (Wu et al., 2016; Baumeister, 2013).

Several themes emerged from the mixed-methods review of the core literature selected for this study. The basis for the framework analysis can be found in appendix 2. Quantitative data was utilised in providing a factual basis for reporting the subjective experiences of patients. For this study, the post-MI state is defined as the time 30 days after the first hospital-diagnosed MI event. Bias in this paper was minimised by applying a structured and rigorous approach to the study process. Patterns of phrases that matched or whose deeper meanings could be linked to likely markers of experience based on themes identified by the evidence selected formed the themes.

Results

Fear and Anxiety

Fear and anxiety are the most consistent psychological effects of post-myocardial infarction for patients. The qualitative studies analysed mentioned fear and anxiety as a feature of the post-myocardial infarction experience (Iles‐Smith et al., 2017; Lewis et al., 2014;  Andersson, Borglin and Willman, 2013; Galdas and Kang, 2010; Walters et al., 2014; Hawkes et al., 2013; Merritt, De Zoysa and Hutton, 2017; Webster et al., 2017). The theme of fear and anxiety emerged due to several factors. However, the most significant was the myocardial infarction itself. Post MI, patients were fearful and anxious because of the likelihood of subsequent events and an elevated sense of mortality. The sense of anxiety and fear was higher for younger patients (those below 55 years of age). The finding was due to additional sources of stress for younger patients such as fear of loss of income, demands of employers and fear of inability to provide for younger families (Andersson, Borglin and Willman, 2013; Walters et al., 2014; Merritt, De Zoysa and Hutton, 2017).

The presence of cardiovascular symptoms, the severity of these symptoms, and subsequent experience of cardiovascular events or admission for the possible cardiovascular event were also important factors in the incidence and extent of fear and anxiety  (Iles‐Smith et al., 2017; Lewis et al., 2014; Andersson, Borglin and Willman, 2013; Walters et al., 2014; Merritt, De Zoysa and Hutton, 2017). Ethnicity, lack of social support or living alone (loneliness), disability, and income were also factors for the prevalence of fear and anxiety among patients in the post-myocardial infarction state with those from an Asian background, those who lived alone and those with low incomes reporting higher levels of fear and anxiety across several studies (Galdas and Kang, 2010; Hawkes et al., 2013; Webster et al., 2017). Only no studies involving the experience of black people were found; hence only the Asian experience is reported as representative of minority experience. Female gender may also be a risk factor for increased fear and anxiety in the post-myocardial infarction state, but the evidence for this is minimal (Walters et al., 2014; Hawkes et al., 2013).

Fear and anxiety in post-MI patients are not unwarranted. Quantitative studies indicate that survivors of myocardial infarctions are at a significantly higher risk of subsequent cardiovascular events and mortality than the general population. Smolina et al. (2012) and Chapman et al. (2018) found that the risk of subsequent cardiovascular events and mortality was considerably elevated for survivors of MI, especially in the first year following the MI. Smolina et al. (2012) found that the risk remains considerable for a period of up to seven years, and survival outcomes were significantly worse for those admitted with subsequent cardiovascular events. Smolina et al. (2012) further found that younger people (<55) faced poorer prognosis compared to older people (>55), although older people faced a higher risk of a second MI. The study also found that women faced a higher risk of a second MI event, and deprivation was also a significant risk factor for a second MI event. Chapman et al. (2018) found that the risk of death in those that had survived a first myocardial infarction beyond 30 days post-event was over 30% higher than that of the general population.

Lack of Physical and Mental Energy

Abnormal tiredness and lack of energy is another consistent feature of the post-MI experience for patients. Open-ended studies and studies that explored broader aspects of quality of life consistently identified lack of energy as an important aspect of the post-MI experience (Galdas and Kang, 2010; Andersson, Borglin and Willman, 2013; Lewis et al., 2014; Merritt, De Zoysa and Hutton, 2017). Studies that focused on the quality of life following a myocardial infarction such as Lewis et al. (2014), Hawkes et al. (2013) and Webster et al. (2017) also found that lack of energy was an important reason for a lower quality of life among patients.

Certain factors either resulted in a higher incidence of lack of energy or a focus on the lack of energy by patients. Focus on lack of energy as a central theme of the post-myocardial infarction experience was considered in studies that focused on younger people or men (Andersson, Borglin and Willman, 2013; Walters et al., 2014; Merritt, De Zoysa and Hutton, 2017). Men were more likely to report a lack of energy as the central theme of post-myocardial infarction experience due to its impact on the perception of their masculinity than women. For younger people, a lack of physical and mental energy was widely reported in response to the effect of the MI on their work and social life. Ethnic minorities (Asian minorities in this case) also reported higher incidences of a lack of energy compared to their white counterparts (Galdas and Kang, 2010; Webster et al., 2017).

Depression

Depression was also a key theme of the post-MI experience across several studies (Andersson, Borglin and Willman, 2013; Hawkes et al., 2013; Walters et al., 2014; Lewis et al., 2014; Webster et al., 2017; Merritt, De Zoysa and Hutton, 2017). Only one study in the selected evidence focused specifically on the question of depression in persons suffering from coronary heart disease. Walters et al. (2014) conducted a study of 803 coronary heart-disease patients, of whom 42% had a history of MI, that discovered that 19% of subjects met the criteria for a diagnosis of clinical depression. Other studies used the Hospital Anxiety and Depression scale and other measures of quality of life scores to ascertain the presence of depression even where it was not clinically relevant (Andersson, Borglin and Willman, 2013; Hawkes et al., 2013; Walters et al., 2014; Lewis et al., 2014; Webster et al., 2017; Merritt, De Zoysa and Hutton, 2017).

The studies identify several factors that influence the likelihood of depression in the post-MI patient. The age of persons in the post-MI state was a factor in the likelihood to report symptoms of depression with younger adults (<55) more likely than older adults (>55) to report symptoms of depression (Walters et al., 2014; Hawkes et al., 2013). Deprivation, unemployment, sedentary lifestyle, and a lack of social support were also found to be strong indicators of the risk of depression (Walters et al., 2014; Hawkes et al., 2013). Ethnicity was also an important factor in the risk for depression in the post-MI state (Galdas and Kang, 2010; Walters et al., 2014; Hawkes et al., 2013; Webster et al., 2017). Female gender also appears to be a risk factor for depression in the post-MI state (Walters et al., 2014).

Poor Quality of Life

Quality of life, particularly the health-related quality of life, was consistently poor based on scores that specifically analysed the subject or indicators from interviews. Studies that focused specifically on the quality of life found consistently low scores for patients in the post-MI state (Hawkes et al., 2013; Lewis et al., 2014; Webster et al., 2017). Other studies used measures that have been used to study health-related quality of life or reported findings from interviews that indicate the lowered quality of life. Walters et al. (2014) found low scores among patients on the Hospital Anxiety and Depression Scale; a tool often used to assess Healthcare-Related Quality of Life. Andersson, Borglin, and Willman (2013) and Merritt, De Zoysa, and Hutton (2017) reported findings such as patients living in constant fear and anxiety, reduced sexual function, and diminished social life due to low energy levels which indicate a reduced quality of life.

The extent to which patients experienced a diminished quality of life in the post-MI phase was subject to several factors. The severity of ischaemic heart disease symptoms, the experience of subsequent cardiovascular events, admission for possible subsequent cardiovascular events, and the presence of chronic comorbidities were the most reliable indicators of diminished quality of life (Hawkes et al., 2013; Walters et al., 2014; Iles‐Smith et al., 2017; Merritt, De Zoysa and Hutton, 2017). Ethnicity was also a factor with persons from minority ethnic groups more likely to report the poor quality of life after a myocardial infarction (Galdas and Kang, 2010; Walters et al., 2014; Hawkes et al., 2013; Webster et al., 2017).

Hawkes et al. (2013) found that younger persons (<55) were more likely to score poorly in quality of life measures related to mental health while older patients (>55) were more likely to score poorly in physical quality of life measures. Deprivation and lack of social support/loneliness also resulted in more likelihood of poor quality of life scores (Hawkes et al., 2013; Walters et al., 2014). Female sex may also be a factor in the poor quality of life scores, although the evidence for this is not reliable in the cohort studies (Hawkes et al., 2013; Walters et al., 2014). Hawkes et al. (2013) also found that unemployment and a sedentary lifestyle were notable factors in the likelihood to report the poor quality of life scores.

Changed Outlook to Life

A changed outlook on life is also widely reported as a consistent feature of the post-MI experience. Phrases such as ‘life will never be the same again,’ ‘shortened horizon,’ ‘acute awareness of mortality,’ ‘new normal,’ and ‘reassessment of priorities’ are prevalent across the study and indicate a change in the outlook of life. Young people (<55) are more likely to have a profound change in their outlook on life. Andersson, Borglin, and Willman (2013) and Merritt, De Zoysa and Hutton (2017) found that young adults reported significant changes in their outlook to life with ‘life would never be the same again,’ ‘shortened horizon,’ ‘viewings own body as unreliable and foreign,’ and ‘having to reassess priorities’ being frequently reported by participants across the two studies. The severity of ischemic heart disease symptoms, significant comorbidities, and subsequent experience of cardiovascular events also negatively affect outlook to life (Iles‐Smith et al., 2017; Hawkes et al., 2013; Lewis et al., 2014). Attendance of cardiac rehabilitation therapy appears to improve outlook to life (Galdas and Kang, 2010; Hawkes et al., 2013; Walters et al., 2014; Webster et al., 2017).

Need to Validate Self-Construct of Illness and Understand Symptoms

The desire to validate one’s understanding of the post-MI state and better understand and judge symptoms was also an essential theme in the post-MI state. Attendance of cardiac rehabilitation therapy was often a means to better understand the post-MI state and validate the self-construct of illness (Galdas and Kang, 2010; Webster et al., 2017). Symptoms of ischemic heart disease were often challenging for patients with indigestion (a potential symptom of a subsequent MI as well as a symptom of a digestive system problem) causing concern among patients (Andersson, Borglin and Willman, 2013; Merritt, De Zoysa and Hutton, 2017; Iles‐Smith et al., 2017). Patients were often fearful of causing unnecessary alarm over mild or unrelated symptoms and underestimating a severe subsequent cardiovascular event. Patients were also aware of the likelihood that medical staff was not giving them full information to protect them from bad news (Andersson, Borglin and Willman, 2013; Iles‐Smith et al., 2017).

DISCUSSION

Overview

The discussion section is another key section of a research paper (Ferrari, 2015). The function of a discussion section is to interpret the results of research and determine the significance of the findings with respect to the research question (Cals and Kotz, 2013; Parkinson, 2011; Ferrari, 2015). The section also offers insights into any new or unexpected findings in the research. Cals and Kotz (2013) argue that an effective discussion is important as it demonstrates the interpretive skills of researchers and demonstrates the quality of the research paper. Parkinson (2011) contends that linguistic skills are crucial to an effective discussion of the findings. This section will analyse the key themes uncovered in the findings section. It will also offer a detailed analysis of the factors that affect the post-myocardial infarction experience of patients. These factors are crucial because they can need to be taken into account in individual cases to ensure patients’ experiences as improved effectively.

Key Themes

From the results, it is clear that there is a significant overlap between the themes as well as the factors affecting them. Fear and anxiety are features of depression, while mental health is an essential aspect of quality of life measures and also affects outlook on life. A lack of energy is also likely to be a factor in anxiety, depression, and outlook on life. The overlapping and interrelated nature of the themes also creates significant overlapping of the factors that affect the experience of these themes. The detailed nature of the results section and the overlapping nature of the themes makes a detailed analysis of each particular theme unnecessary.

Myocardial infarction is a dramatic near-death experience in many cases (McKee et al., 2018). Patients are often aware of the gravity of the situation due to the prevalence of information and depiction in popular culture. Several studies focusing on the emotional aspect of the myocardial infarction experience have found that fear of death and anxiety are critical elements of the experience (Van Beek et al., 2012: Albarqouni et al., 2016). The thematic analysis shows that fear and anxiety extend well into the post-MI state. The higher incidence among patients with severe symptoms of ischemic heart disease or those readmitted with potential ischaemic heart disease is probably due to the awareness that the symptoms and events signify a worsening situation and imply a poor prognosis. Quantitative data backs this awareness; Smolina et al. (2012) and Chapman et al. (2018) found that the risk of subsequent cardiovascular events and mortality was considerably elevated for survivors of MI, especially in the first year following the MI.

The finding of elevated levels of depression among survivors of myocardial infarctions is not surprising (Elderon and Whooley, 2013; Atlantis et al. 2012; Windle, M. and Windle, 2013; Doherty and Gaughran, 2014). High levels of fear and anxiety, a common feature of the post-MI experience, as stated above, are linked to depression (Izard, 2013; Elderon and Whooley, 2013). The presence of comorbidities, which is also common in post-MI patients and includes a history of MIs, has also been linked to depression (Barua et al., 2010; Elderon and Whooley, 2013). The factors identified in the evidence that are likely to increase depression post-MI have also been identified in the literature as independent risk factors for depressive disorders (Windle, M. and Windle, 2013; Doherty and Gaughran, 2014). Living alone (lack of social support), low socio-economic status (deprivation), chronic comorbidities, and sedentary lifestyle (such as due to low energy levels) have been independently identified as risk factors for depression in the elderly (Barua et al., 2010; Elderon and Whooley, 2013).

Poor quality of life and changed outlook to life is also unsurprising findings in the post-MI cohort. Physical health, mental health, sexual function, and social life are all critical aspects of quality of life measures (Fayers and Machin, 2013). The evidence shows that myocardial infarction, its associated comorbidities, ischemic heart disease, and the therapies for these conditions affect all these key scores negatively. Myocardial infarctions can often seem like near-death experiences as they bring a person’s mortality into sharp focus (Buchta and Saleem, 2018). The post-MI state also requires significant life changes for most patients, and in this context, it is not surprising that outlook to life is significantly affected.

The most unexpected finding of the thematic analysis is the centrality of lack of energy to the post-MI experience. Ischemic heart disease is characterised by several symptoms such as chest pain and pressure, palpitations, shortness of breath, dizziness, light-headedness, indigestion, oedema, cough, and respiratory congestion, and fatigue among others (Zipes et al., 2018). Despite the abundance of symptoms, the post-MI experience appears to be heavily characterised by fatigue, especially among young people. Fatigue may stand out among post-MI patients because of its unexpected severity and lack of focus on it by healthcare providers when explaining expected symptoms. The symptom also appears to be the most consequential for younger people as it affects most areas of their lives. Poor understanding of symptoms needed to validate self-construct of illness may also be due to poor health information provision. The centrality of vital exhaustion to the post-MI experience is supported by other evidence (Johansson et al., 2010; Smith et al., 2011;  Fredriksson-Larsson, Alsen and Brink, 2013). Alsén and Brink (2013) and Williams et al. (2010) found that the extent of vital exhaustion may be a strong prognostic indicator for subsequent cardiovascular events and mortality.

Factors that Affect the Post-MI Experience

Physical Health Factors

The evidence shows that physical health factors, particularly those related to the MI, play a key role in how patients experience the post-MI state. The severity of the symptoms of ischemic heart disease, the presence of comorbidities, and the experience of subsequent cardiovascular events significantly influence the experience of the post-MI state. These factors are critical because they either directly impact the quality of life or indicate an unfavourable prognosis for patients. Understanding how these factors affect patients in the post-MI state will help healthcare providers improve the experience for patients (Moradkhani, Beckman and Tabibian, 2013).

Age

The evidence shows that age is also a key factor in the post-MI experience. Younger and older patients experience the post-MI state differently, probably because of different socio-economic pressures and different outlooks to life (Andersson, Borglin and Willman, 2013; Merritt, De Zoysa and Hutton, 2017). The two studies were broadly similar and had a small number of subjects with Andersson, Borglin and Willman (2013) taking a phenomenological-hermeneutic approach with 17 subjects and Merritt, De Zoysa and Hutton (2017) taking an interpretive phenomenological approach with 10 subjects.  Younger people face additional pressures such as demands of employers, a sudden collapse of social life, dependent children, and more health demands (Falvo and Holland, 2017). A change in outlook in terms of the shortened horizon is also more profound in younger people. The differences in the experience of the post-MI state could explain the surprise finding that younger patients face higher mortality despite having a lower risk of subsequent cardiovascular events and fewer comorbidities (Smolina et al., 2012).

Ethnicity

It is widely acknowledged that Black, Asian, and Minority Ethnic (BAME) groups face inequality and worse outcomes in the healthcare setting (Bleich et al., 2012; Jackson, 2018; Hicken et al., 2018). Despite their status as the ethnic group most likely to experience cardiovascular disease in the UK, South East Asians still face significant delays in access to treatment during a myocardial infarction compared to their white counterparts (Kendall et al., 2013). The evidence suggests that the disparity in outcomes extends to the qualitative experience of the post-MI state. However, recent quantitative data suggests that SE Asians do not face worse mortality post- MI when the context is factored in. Gholap et al. (2015) found no difference in mortality between two groups when adjusted for differences in risk factors and age in a retrospective cohort study of patients admitted between 2002-2008 for MI as SE Asians have more risk factors and more comorbidities. This finding would suggest that other factors, such as language barrier and cultural outlook, play a role in the qualitative experience.

Socio-economic Status

Socio-economic status is widely acknowledged as a significant factor in both health care status and healthcare outcomes (Pearce et al., 2010; Grintsova, Maier and Mielck, 2014; Kivimäki et al., 2020). Unsurprisingly, it plays a central role in the post-MI experience. People from deprived backgrounds are more likely to experience delays in receiving healthcare, experience poor healthcare outcomes, have significant comorbidities, have poor adherence to therapy, lack social support, and have poor mental health status (Cookson et al., 2016; Kivimäki et al., 2020). All these aspects of socio-economic status negatively impact the post-MI experience according to the evidence used for this paper.

Variable Factors that Improve the Post-MI Experience

From the evidence, it is clear that the post-MI experience is broadly negative for most patients. The post-MI experience is characterised by poor physical and mental health, diminished social and economic function, elevated risk of mortality, significant disruption of life, and significant changes to the view of life. However, the evidence indicates three key variable factors that healthcare providers can control that result in better experience in the post-MI state. Attendance of cardiac rehabilitation therapy, prevention of subsequent cardiovascular events, and the provision of accurate and informative information on ischaemic heart disease and its symptoms all improve the experience.

Evidence indicates that attendance of cardiac rehabilitation therapy results in a higher quality of life scores, a better understanding of disease and mitigation factors, and better mental health scores in the post-MI state (Galdas and Kang, 2010; Webster et al., 2017). This evidence is supported by other studies conducted on the same topic (Turk-Adawi and Grace, 2015; Mampuya, 2012; Braverman, 2011; Dunlay et al., 2014). Cardiac rehabilitation therapy is beneficial across socio-demographic cohorts, although the benefit is lower for minority groups. Prevention of subsequent cardiovascular events, even where such preventative action does not impact mortality, also improves the post-MI experience (Iles‐Smith et al., 2017; Lewis et al., 2014). The positive effect is probably due to the elimination of the mental health burden of subsequent cardiac events and suggests that efficient control of symptoms may also be beneficial. The provision of accurate and exhaustive information on cardiac status, prognosis, symptoms, and likelihood of subsequent events is also associated with a positive experience as patients know what to expect.

STRENGTH AND LIMITATIONS OF REVIEW

Strengths

The rigorous and systematic approach in this selection of evidence is a vital strength of the study. The approach resulted in the selection of the best evidence for the review. The approach also promoted the use of peer-reviewed primary data only for the core evidence of the paper. The utilisation of peer-reviewed primary data only ensured that bias was a minimal factor in the review. The approach is also evidence-based, making it consistent with modern healthcare practice (Cullum et al., 2013; LoBiondo-Wood and Haber, 2017; Schneider et al., 2016).

The use of mixed-methods systematic review rather than the traditional single-method approach is also a key strength of the study. Mixed-methods research is deemed to be superior to single-method studies because it incorporates both aspects of both qualitative and quantitative studies (Terrell, 2012; Green et al., 2015; Almalki, 2016). For instance, in this study, quantitative data provided context for the qualitative data. Quantitative evidence supplemented the qualitative experience and provided a basis for or grounds for examining qualitative data.

The focus on the UK context in the study constitutes another strength of the study. Often, US studies crowd out UK studies and are presented as evidence for UK healthcare workers despite the significant contrast between the two countries’ healthcare systems. For instance, the US healthcare system is not free, suggesting that access and adherence problems for poor people and ethnic minorities would be worse than in the UK.

Limitations

A fundamental weakness of the study is the focus on a limited amount of evidence. The focus on UK evidence also limited the scope of the paper. This weakness resulted in a limited depth of the evidence available, especially concerning ethnic minorities and women. There is a shortage of recent literature on the qualitative and quantitative experience of the post-MI state for black citizens, and this was not sufficiently explored.

The novelty of the researcher in conducting an extensive review of literature is also a potential limitation of the study. Fortunately, sufficient guidelines were offered, and it is hoped that this weakness did not have an outsized impact on the quality of the paper. The author will only get stronger in subsequent reviews.

IMPLICATIONS FOR PRACTICE AND RECOMMENDATIONS

Implications

From the evidence, it is clear that the post-MI experience is overwhelmingly negative for most patients. Nurses and other healthcare providers must understand that the phase is characterised by negative changes, poor physical and mental health, and a diminished quality of life rather than gratitude for being alive. A better understanding of the experiences of patients should help nurses to provide focused care depending on the unique factors of individual cases (Parekh et al., 2011). For instance, younger patients need a different approach to older patients. Ethnic minorities also need special consideration as their experience is worse than that of white patients.

Nurses and other healthcare workers should also be aware of the measures that improve the post-MI experience for patients such as cardiac rehabilitation therapy, appropriate symptom control, prevention of subsequent CV events, provision of accurate and complete information on the illness and symptoms.  Nursing leaders can incorporate these evidence-based measures into management guidelines (Cullum et al., 2013).

Recommendations

There is a need for further exploration of the post-MI experience of ethnic minority groups. Evidence on the experiences of black minority groups, in particular, is lacking (Greenhalgh et al., 2016). More quantitative evidence on the comparison of post-MI mortality between white and minority ethnicities is needed. The post-MI experiences of minorities in the UK requires its extended literature review.

Further research should also focus on the experience of women in the post-MI state specifically. Recent data suggest that the difference in how men and women experience myocardial infarctions is more extensive than previously thought (Barrett, 2018; Sechtem, 2013; Yahagi et al., 2015). Whether the stark sex difference extends to the post-MI experience needs to be assessed in-depth.

Finally, there is a need for rigorous research into evidence-based approaches to improving the post-MI experience of patients. The experience is overwhelmingly negative for most patients. Cardiac rehabilitation therapy improves the experience, but it is not enough on its own for most patients (Yohannes et al., 2010; Shepherd and While, 2012; Munro et al., 2011) . Better approaches are needed.

CONCLUSION

Focus Question: What are The psychological Experiences of Patients post-myocardial infarction?

The exhaustive analysis of the evidence selected provides a clear answer to this focus question. The post-MI experience for patients in the UK setting is overwhelmingly negative. The experience is characterised by constant fear and anxiety, a higher likelihood of depression, unusual fatigue, diminished quality of life, poor understanding of illness and symptoms, and a negative outlook on life. Certain factors affect post-MI experience. Severe symptoms, subsequent cardiovascular events, low socio-economic status, lack of social support, poor understanding of illness and symptoms, BAME demographic, younger age of MI event, and poor overall physical and mental health are associated with a worse experience. Cardiac rehabilitation therapy, reasonable control of symptoms, prevention of subsequent CV events, and a good understanding of illness and symptoms result in a more positive experience. Nurses need to understand the post-MI experience of patients to enable targeted evidence-based approaches to improve the experience.

APPENDICES

Appendix 1: Summary of Evidence

ARTICLES	SUMMARY OF FINDINGS
Andersson, E.K., Borglin, G. and Willman, A., 2013. The experience of younger adults following myocardial infarction. Qualitative Health Research, 23(6), pp.762-772.	The study is a primary qualitative study conducted in the UK. 17 detailed interviews of young adults (<55) during the first year after an MI to make sense of their experience. The phenomenological-hermeneutic method was used to analyse data. Findings: Abnormal fatigue and its impact on patient’s socio-economic life was the key theme.
Chapman, A.R., Shah, A.S., Lee, K.K., Anand, A., Francis, O., Adamson, P., McAllister, D.A., Strachan, F.E., Newby, D.E. and Mills, N.L., 2018. Long-term outcomes in patients with type 2 myocardial infarction and myocardial injury. Circulation, 137(12), pp.1236-1245.	This primary quantitative study sought to determine long term outcomes of survivors of type 2 MI by reporting all-cause mortality, non-cardiovascular death and incidence of major cardiovascular events in five years. Findings: ⅔ of patients were dead at 5 years; the presence of coronary artery disease was a major indicator of risk for subsequent cardiovascular events.
Galdas, P.M. and Kang, H.B.K., 2010. Punjabi Sikh patients’ cardiac rehabilitation experiences following myocardial infarction: a qualitative analysis. Journal of Clinical Nursing, 19(21‐22), pp.3134-3142.	This primary interpretive qualitative study used in-depth McGill Illness Narrative Interview schedule interviews to assess the post-MI experience of 15 Punjabi Sikh participants who were attending cardiac rehabilitation therapy. Findings: Identified themes were cardiac rehabilitation experience: ‘making sense of the diagnosis’, ‘practical dietary advice’, ‘ongoing interaction with peers and the multi-disciplinary team’ and ‘transport and attendance’.
Hawkes, A.L., Patrao, T.A., Ware, R., Atherton, J.J., Taylor, C.B. and Oldenburg, B.F., 2013. Predictors of physical and mental health-related quality of life outcomes among myocardial infarction patients. BMC cardiovascular disorders, 13(1), p.69.	This primary qualitative study sought to assess factors affecting physical and mental health-related quality of life outcomes among myocardial infarction patients. The research used the Short Form-36 six months after the first MI to assess physical and mental health aspects of HRQoL. Findings: Old age, unemployment, low baseline physical and mental HRQoL score, and a sedentary lifestyle were predictors of poor physical HRQoL. Younger age, low baseline mental HRQoL, depression and lack of social support were predictors of poor mental HRQoL.
Iles‐Smith, H., Deaton, C., Campbell, M., Mercer, C. and McGowan, L., 2017. The experiences of myocardial infarction patients readmitted within six months of primary percutaneous coronary intervention. Journal of clinical nursing, 26(21-22), pp.3511-3518.	The study is a UK qualitative primary research paper that assessed the experience of patients readmitted for possible ischemic heart disease at least six months after first MI. Used semi-structured in-depth interviews that were analysed using framework analysis. Findings: 25 participants with 1-4 readmissions. Experience characterised by anxiety, uncertainty and inability to determine the cause of symptoms; Fear of experiencing further MI, and; Insufficient opportunity to validate self-construction of illness.
Lewis, E.F., Li, Y., Pfeffer, M.A., Solomon, S.D., Weinfurt, K.P., Velazquez, E.J., Califf, R.M., Rouleau, J.L., Kober, L., White, H.D. and Schulman, K.A., 2014. Impact of cardiovascular events on change in the quality of life and utilities in patients after myocardial infarction: a VALIANT study (valsartan in acute myocardial infarction). JACC: Heart Failure, 2(2), pp.159-165.	The study is a UK qualitative primary research paper to assess the effect of non-fatal cardiovascular events on Health-Related Quality of Life in survivors of MI. A VALIANT (Valsartan In Acute Myocardial Infarction) trial of 14,703 survivors of MI. 17% experienced CE and did an EQ-5D with 5 questions. Findings: Survivors who experienced second CE had considerably lower HRQoL scores compared to those who did not.
Merritt, C.J., De Zoysa, N. and Hutton, J.M., 2017. A qualitative study of younger men’s experience of heart attack (myocardial infarction). British journal of health psychology, 22(3), pp.589-608.	This primary paper used a Qualitative research design based on semi-structured in-depth interviews to assess the post-MI experience of 10 male participants under the age of 45. The analysis was done using interpretative phenomenological analysis. Findings: Three key themes; I’m less of a man, Shortened horizons, and life loses its colour.
Smolina, K., Wright, F.L., Rayner, M. and Goldacre, MJ, 2012. Long-term survival and recurrence after acute myocardial infarction in England, 2004 to 2010. Circulation: Cardiovascular Quality and Outcomes, 5(4), pp.532-540.	This paper was a quantitative retrospective study of long-term survival and incidence of cardiovascular events in England between 2004-2010. The records of 387,452 patients who survived an initial MI for at least 30 days in that timeframe. Findings: The risk of death was highest during the first year post-MI. The risk of death at 7 years was twice that of the general population. The risk of a subsequent MI was thrice that of the wider population.
Webster, R.A., Thompson, D.R., Larkin, D., Mayou, R.A. and Martin, C.R., 2017. Quality of Life in a Mixed Ethnic Population after Myocardial Infarction. European Journal for Person Centered Healthcare, 5(3), pp.295-299.	The paper is a primary qualitative UK study that sought to compare the quality of life outcomes based on ethnicity (SE Asians and white people) during the post-MI experience. The study involved a 2×2 mixed group design with repeated QoL measures using the Short-Form 36-Item health survey and the Hospital Anxiety and Depression Scale. Findings:  Significant differences in scores at two weeks with SE Asians scoring well below whites on both scores. Both groups returned significant improvement on scores at three and six months, although the improvement was more pronounced for white participants.
Walters, P., Barley, E.A., Mann, A., Phillips, R. and Tylee, A., 2014. Depression in primary care patients with coronary heart disease: baseline findings from the UPBEAT UK study. PloS one, 9(6).	The paper is a primary qualitative UK study that assessed the link between coronary heart disease and depression. The study involved a purposeful selection of participants with CHD who were assessed for ischemic heart disease symptoms, depression, QoL measures, and social difficulties. Findings: living alone, chest pain, and disability are significant predictors of depression in persons with ischaemic heart disease.

Our psychology writing team offer a wide range of services which are included but not limited to:
– Psychology Coursework Writing Help
– Psychology Dissertation Writing Service
– Psychology Essay Writing Service
– Psychology Dissertation Help
– Psychology Assignment Writing Service
– Psychology Essay Writers

Peachy Essay is a well reputed dissertation writing company that has all your requirements at heart. Our company genuinely offers the following services;

– Dissertation Writing Services
– Write My Dissertation
– Buy Dissertation Online
– Dissertation Editing Services
– Custom Dissertation Writing Help Service
– Dissertation Proposal Services
– Dissertation Literature Review Writing
– Dissertation Consultation Services
– Dissertation Survey Help