Jeffrey L. Birk - US grants

Acute coronary syndrome (ACS; myocardial infarction or unstable angina) is a leading cause of morbidity and mortality in the U.S., with >1 million cases per year. Survivors are at high risk for recurrent cardiovascular disease (CVD) events, particularly if they do not adhere to risk- reducing medications. Unfortunately, nonadherence among ACS patients is very common (~50%), and no effective, scalable interventions exist. Addressing medication nonadherence in ACS patients requires an experimental medicine approach to identify specific mechanisms of behavior change in populations for whom those mechanisms are most relevant and modifiable. Accumulating evidence suggests that the many patients who develop post-traumatic stress disorder (PTSD) symptoms following ACS view their medications as reminders of their cardiac event and their future CVD risk. Ironically, although it has rarely been studied outside of cancer survivors, this fear of recurrence (FoR) may undermine medication adherence in ACS patients. This project will use the Science of Behavior Change (SOBC) experimental medicine approach to investigate FoR as a putative mechanism of behavior change with respect to aspirin adherence among ACS patients with early PTSD symptoms at hospital discharge. We will test a cognitive- affective intervention that has been shown to reduce FoR in cancer survivors, that is delivered electronically (IPad) in the patient?s home. We have begun adapting this intervention for ACS, and will test it using a double-blind randomized controlled design. We will enroll n=100 ACS patients with high acute stress disorder symptoms at discharge, and assess FoR and future time perspective at inpatient bedside, then train participants on the IPad intervention. Participants will complete the intervention over four weeks in eight half-hour sessions, twice each week. Medication adherence will be measured electronically using eCAPS. We will reassess FoR and future time perspective at 1 month follow up, as well as electronically assess cognitive-affective change throughout the intervention period. We will estimate associations among ACS-induced PTSD, FoR, and future time perspective, and their association with medication adherence. Then, we will assess whether the intervention successfully engages the target mechanism (FoR). Finally, we will test whether the intervention improves adherence in the 2 months after hospital discharge, and whether any intervention effect is due to reduction in FoR. This will be the first study to identify, and perhaps modify, a cognitive/affective mechanism of adherence behavior in ACS patients at high risk for ACS recurrence and mortality.

With advances in healthcare and effective public health campaigns, the survival rate after cardiac arrest (CA) has more than doubled during the last decade. However, as highlighted by a scientific statement from the American Heart Association in 2020, CA patients remain at markedly elevated risk for poor long-term recovery after leaving the hospital. We have shown that the experience of CA can be a psychologically distressing event that induces depressive and posttraumatic stress disorder (PTSD) symptoms in >30% of patients. Further, these symptoms were associated with a tripling of risk for secondary cardiovascular disease (CVD) and mortality risk in our prior work. Despite a growing interest in conducting psychological interventions, there is no reliable method for preventing negative psychological factors (NPF) after acute cardiac events. Critically, modifiable positive psychological factors (PPF) are associated with improved quality of life (QoL), greater independence in activities of daily living (ADL), healthier behaviors, improved (higher) cardiac vagal control, fewer adverse cardiovascular events, and lower risk of dying in CVD patients. The most promising PPF in this regard are a sense of optimism, experiences of positive affect, and a belief that one?s life has purpose even in the face of the depression and distress that often follow serious cardiac events. It is unknown whether CA survivors may benefit from PPF in the same way as other CVD patients seem to do. Although the rates of elevated NPF are even higher in patients after CA than in patients after heart attack and stroke, many CA survivors actually report a positive attitude and a belief that they have a fortuitous opportunity for ?a second chance at life.? The first aim of the study is to test whether PPF and NPF are associated with the measures of recovery that are most important to patients? everyday lives?QoL and ADL?in the year after the CA in a racially and ethnically diverse sample of CA survivors. The second aim is to test whether PPF and NPF are associated with a potential behavioral mechanism underlying recovery: changes in physical activity in the first 6 months after the CA. The third aim is to determine the demographic and medical factors that predict who develops PPF and NPF after CA. We will enroll a cohort of 228 CA patients from the intensive care units (ICU) of NewYork-Presbyterian Hospital. We will assess patients? PPF and NPF at hospital discharge (median 21 days post-CA). We will conduct follow-up assessments by phone at 3, 6, and 12 months after the CA. In the week immediately following hospital discharge and again 6 months later, we will monitor physical activity via wrist- worn actigraphy, daily positive and negative affect using mobile ecological momentary assessment, and cardiac vagal control via a chest patch. CA accounts for more than half of all cardiac deaths, and is the third leading cause of death and disability in the US. Malleable PPF and NPF may be targets for improving QoL and returning CA survivors to independent lives. This study will be the first to test the potentially cardioprotective PPF and the potentially harmful NPF to investigate how long-term recovery after CA may be improved.