INTRODUCTION:

Cardiovascular diseases have become the leading cause of morbidity and mortality.¹ Cardiovascular diseases (CVD) includes diseases which affects the heart structurally and functionally. Coronary artery disease refers to the diseases that results from the decrease in blood supply of the heart that results from a decreased blood supply to the heart muscle².

The 2017 Heart Disease and Stroke Statistics update of the American Heart Association (AHA) has recently reported that an estimated 92.1 million US adults have at least one type of CVD.

An acute myocardial infarction also known as “heart attack” is a life-threatening condition characterized by the formation of localized necrotic areas within the myocardium². According to the national readmission database in the year 2013 and 2014 there are 11,16933 hospitalizations with a primary diagnosis of acute myocardial infarction⁷.

Myocardial infarction (MI) is an unexpected life-threatening event which is perceived as stressful by many patients who may expect death or serious disability⁹. Patients following myocardial infarction may find it difficult to adjust to their new health situation¹¹. Post-traumatic stress disorder is the development of characteristic symptoms after exposure to extreme stress. Patients with PTSD showed significant impairments in psychosocial functioning¹³.

Coping is deﬁned as an individual's use of behavioral and cognitive strategies to modify adverse aspects of their environment, as well as minimize or escape internal threats induced by stress or trauma. Coping can be categorized into active and avoidant strategies. Coping strategies inﬂuence PTSD development.

As survival rates from myocardial infarction (MI) and cardiac arrest (CA) have increased with advanced medical technology both in the community (e.g., automated external defibrillator) and in-hospital, more people are living to remember these life-threatening events. As a result, the relationship between cardiac events and subsequent traumatic symptoms is also coming into light. ¹⁸. Therefore, the assessment of post-traumatic stress disorder and its relationship between coping strategies among post-acute myocardial infarction patients is important.

NEED AND SIGNIFICANCE OF THE STUDY:

Coronary heart disease is a major cause of mortality and morbidity among all over the world. According to a report of World health organization (WHO) in 2005, cardiovascular disease caused 17.5 million (30%) of the 58 million deaths that occurred worldwide. In that total 80% of chronic disease deaths occur in low and middle – income countries where they have a major impact on their local economies¹⁹.

Cardiovascular diseases are the major causes of mortality in the Indian subcontinent, causing more than 25% of deaths. Case control studies conducted by WHO, have indicated that tobacco use, obesity, high blood pressure, high cholesterol levels, diabetes, low consumption of fruits and vegetables, sedentary life styles and psychosocial stress are important determinants of cardiovascular diseases in India¹⁹.

Various studies conducted at US have reported the prevalence of post myocardial infarction – post traumatic stress disorder to be as high as 30%, but a meta-analysis of 24 observational cross-sectional studies estimated the prevalence to be 12%. This is much higher than the prevalence of PTSD in the general population (10%–12% in men and 5%–6% in women)²⁰.

Studies of Indian immigrants and cross-sectional studies in India, have demonstrated that CAD is present in Indians and that its prevalence is several folds higher than in industrialized nations. Kerala with a population of over 33 million is the most advanced state in epidemiological transition and has the highest prevalence of CAD risk factors in India. The overall crude and age- adjusted prevalence of any CAD in Kerala was 16.6 and 12.5% respectively²².

Severe cardiac disease like myocardial infarction or the symptoms of angina pectoris are often perceived by the individual as a life-threatening and devastating event. Myocardial infarction (MI) is experienced as a traumatic event by some of the people who suffer from and may result in posttraumatic stress disorder (PTSD). The outcome of each patient will be different according to the prognosis and the ability to cope up with stressful situations.¹ Considering these facts, the investigator felt the need to conduct a study to assess the relationship between coping strategies and development of post-traumatic stress disorder in patients after an acute myocardial infarction.

PROBLEM STATEMENT:

A study to assess the relationship between coping strategies and development of post-traumatic stress disorder in patients after an acute myocardial infarction in a selected hospital, Kottayam

OBJECTIVES:

1. Assess the coping strategies in different domains of post MI patients

2. Assess post-traumatic stress disorder among post MI patients

3. Find the correlation of coping strategies and post-traumatic stress disorder among post MI patients.

4. Determine the association of PTSD with selected demographic and clinical data

OPERATIONAL DEFINITIONS:

Coping strategies

Coping strategy in this study refers to an individual's use of behavioral and cognitive strategies to minimize or escape the internal threats induced by acute myocardial infarction, which is measured using COPE scale, which consist of three primary scales: Problem focused coping, Emotion focused coping and dysfunctional coping.

Post-traumatic stress disorder:

Post-traumatic stress disorder (PTSD) in this study refers to the development of characteristic symptoms after exposure to an acute MI, which is considered as an extreme stress event, measured by using UK post-traumatic symptom scale-14.

Patients with acute myocardial infarction:

Patients with acute myocardial infarction refers to those patients whose diagnosis will be confirmed by the treating cardiologists on the basis of electrocardiogram and enzyme changes in the time period of one month to six months after an acute MI.

HYPOTHESIS:

All the hypotheses are tested at 0.05 level of significance

H₁: There is significant relationship between post-traumatic stress disorder and coping strategies.

H₂: There is significant association between post-traumatic stress disorder and selected demographic and clinical data.

ASSUMPTIONS:

1. Patients after myocardial infarction may develop post-traumatic stress disorder.

2. Adoption of effective coping strategies may reduce the PTSD.

MATERIALS AND METHODS:

Research design

Correlational study design

Setting of the study:

The study was conducted in the Cardiology OPD of a selected hospital, Kottayam.

Conceptual framework:

Betty Newman’s theory

Research approach:

Quantitave approach

Population:

Population in the present study is acute myocardial infarction patients who had come for review in the cardiology OPDs of Caritas Heart Institute.

Sample size:

The study sample consists of 100 post myocardial infarction patients from the cardiac OPDs of Caritas Heart Institute.

Inclusion criteria:

· Patients who had come for follow up in cardiac OPD, post-acute myocardial infarction within one to six months.

· Patients who are willing to participate in the study.

· Patients who are able to read and write Malayalam

Exclusion criteria:

· Post MI patients within a month, who are critically ill and admitted in the hospital.

· Patients who are on treatment for psychiatric illness.

Tools/instruments:

In this study the data collection instruments used are,

· Tool 1: Structured Questionnaire on socio-demographic data and Clinical data.

· Tool 2: Modified UK PTSS 14 questionnaire

· Tool 3: Modified BRIEF COPE scale

Tool 1: Structured Questionnaire to collect socio demographic data and clinical variables

It includes the information regarding the client such as age, gender, education, occupation, religion, socio-economic status, type of family and marital status. The clinical variables, includes the information regarding type of treatment, previous history of mental disorder, family history of cardiovascular disorder, no of days of hospitalization, no of days of ICU stay, history of psychiatric referral and habits.

Tool 2: Modified UK PTSS 14 questionnaire

Post-traumatic stress disorder of post myocardial infarction patients will be measured using UK PTSS questionnaire. UK PTSS 14 consist of 14 questions.

Tool 3: Modified BRIEF COPE scale:

Coping strategies of post myocardial infarction patients will be measured using Brief cope scale, which is a four-pointLikert scale which consist of 14 two-item subscales.

Score interpretation:

PTSD scale was rated from 1 (never) to 7 (always), summed with equal weighing to derive a total score ranging from 14 to 98.

For the research analysis purpose, the PTSD symptomology was graded as follows:

· PTSD symptomatology: Above 45

· Borderline PTSD: Between 30 - 45

· No PTSD: Below 30

Modified BRIEF COPE scale, the individual item score ranged from 1 (not doing it at all) to 4 (doing it a lot). The items were categorized into three dimensions

For analysis purpose the scores allotted are:

· Problem focused coping – 24

· Emotion focused coping - 40

· Dysfunctional coping - 48

The domain of coping strategies were graded as follows:

· Problem focused coping -

Poor (below 8), Average (9-16), Good (17-24)

· Emotion focused coping -

Poor (below 13), Average (14- 27), Good (28-40)

· Dysfunctional coping -

Poor (below 16), Average (17-32), Good (33-48)

RESULTS:

Section I: Description of samples based on socio demographic data and clinical variables.

The study results shows that about 57% of samples belongs to the age group of above 60 years, and majority (76%) of samples were male. Less than half (30%) of samples with post-acute myocardial infarctions completed high school and only 5% of samples were postgraduates. About 24% of samples were private employees, whereas only 7% were daily wagers. More than half (61%) were Christians and 14% were Muslims.Majority (86%) of samples were APL. About 76% of samples with acute post myocardial infarction belongs to nuclear family. Majority (80%) of the samples were married.

More than half (61%) of the samples with acute post myocardial infarction have undergone angioplasty and 12% of the patients have undergone thrombolytic therapy. About 71% of the patient are having no family history of cardiovascular disease. Nearly half (48%) of the samples had 3-6 days of hospitalization and 11% were admitted only for 1-3 days. More than half (67%) of the samples have stayed in the ICU for 1-2 days and 11% of the patients stayed in ICU for above 5 days. Majority (72%) of the samples having no bad habits, whereas only 5% had the habit of smoking and alcoholism.

Section II: Findings related to coping strategies under the different domains of cope scale: emotion focused coping, problem focused coping and dysfunctional coping strategies:

The study findings revealed that 42% were using emotion focused coping skills, 26% were using problem focused coping skills and 74% of the samples used dysfunctional coping skills effectively. In the present study, the emotion focused coping (65.5%) was the most frequently used coping strategy by the samples and the least used was dysfunctional coping strategy (40.41%), among the domains of coping strategies

Section III: Findings related to grading of samples based on their post-traumatic stress disorder after an acute MI

Table 1 Frequency and percentage distribution of samples with acute post myocardial infarction based on the post-traumatic stress disorder n=100

Score	Grade	Frequency	percentage
Score	Grade	(f)	(%)
Above 45	PTSD symptomology	10	10
30 – 45	Borderline PTSD	27	27
Below 29	No PTSD	63	63

The study findings revealed that more than half (63%) of samples with acute post MI had no PTSD, 27% had borderline PTSD and only 10% had PTSD symptomology. The findings from the study showed that mean percentage score of post-traumatic stress disorder was 27.15. The study results concluded that, majority of the patients were having no PTSD symptoms.

Section IV: Findings related to relationship between coping strategies and post-traumatic stress disorder among post MI patients.

The study results showed that the correlation coefficient (r = -0.385, p<0.05), between emotion focused coping strategies and post-traumatic stress disorder which indicates that there is a moderate negative correlation between post-traumatic stress disorder and coping strategies in samples with acute post myocardial infarction.

The correlation coefficient (r = -0.204, p<0.05) between post-traumatic stress disorder and problem focused coping strategies which indicates that there is a weak negative correlation between post-traumatic stress disorder and problem focused coping strategies.

The correlation coefficient (r = 0.280, p<0.05), between post-traumatic stress disorder and dysfunctional coping strategies which indicates that there is a weak positive correlation between post-traumatic stress disorder and dysfunctional coping strategies

Section V: Findings related to association between post-traumatic stress disorder and selected demographic and clinical data

The Fischer’s exact test was computed between the post-traumatic stress disorder and selected socio demographic and clinical variables.

The study results revealed that there was a significant association between post-traumatic stress disorder and selected sociodemographic and clinical variables like no. of days of hospitalization [10.413 (p = 0.036)]

The study findings also revealed that there was no significant association between post-traumatic stress disorder with the selected demographic and clinical variable like age, sex, education, occupation, religion, socio-economic status, type of family, marital status, type of treatment, family history of cardiovascular disease and no. of days of ICU stay.

DISCUSSION:

The present study was conducted to assess the relationship between coping strategies and development of post-traumatic stress disorder in patients after an acute myocardial infarction.

Section I: Distribution of samples based on socio demographic data and clinical variables.

The socio demographic data selected for the study were age, gender, education, occupation, religion, socio-economic status, type of family and marital status. The clinical variables include the information regarding type of treatment, previous history of mental disorder, family history of cardiovascular disorder, no of days of hospitalization, no of days of ICU stay, history of psychiatric referral and habits.

Frequency and percentage distribution of socio demographic variables data revealed in the present study was, about 57% of samples belongs to the age group of above 60 years and majority (76%) of samples were males. This study finding are consistent with the results of other research studies which showed that majority of the samples with acute MI were above 60 years and are males^14,17,39. These findings were not consistent to the other research studies where they reported that most of the samples with myocardial infarction²¹ belong to the age group of less than 60 years

The study findings also revealed that less than half 30% of samples had completed high school and only 5% of samples were postgraduates. This finding were contradictory with another research study, which showed that 13.4% had completed high school and 23.2% were graduates⁴⁵.

The present study findings show that about 24% of samples were private employees, whereas only 7% were daily wagers. But in another research study, they reported that nearly half (44%) of the patients with myocardial infarction were unemployed²¹.

Frequency and percentage distribution of clinical variables revealed that more than half (61%) of the samples with acute post myocardial infarction have undergone angioplasty and 12% of the patients have undergone thrombolytic therapy. These findings cannot be related to another research study, where they reported only 9% of the samples with myocardial infarction have undergone revascularization procedure¹⁷.

The results from the present study revealed that about most (71%) of the patient are having a family history of cardiovascular disease. This study finding were not comparable with the results of other research studies which showed that majority (74.6%) of the samples with acute MI had a family history of cardiovascular disease³⁸.

The present study also showed that majority (72%) of the samples are having no bad habits, whereas only 5% had the habit of smoking and alcoholism. But in another study, it was pointed out that nearly half, (43%) had a habit of alcoholism³⁸

Section II: Assessment of coping strategies under the different domains of cope scale: emotion focused coping, problem focused coping and dysfunctional coping strategies

In the present study, mean percentage score of emotion focused domain was in majority (65.5) and minimum mean percentage was in dysfunctional coping (40.41). Therefore, it can be concluded that, patients with post-acute myocardial infarction were commonly using emotion focused coping among the domains of coping strategies. These findings were not consistent to a research study¹⁷ where they reported that patients used more problem-focused coping (M = 51.15, SD = 15.29) than emotion-focused coping (M = 41.92, SD = 7.37) in which, they recruited the patients after two months of initial diagnosis. This may be due to the fact that, as the duration of post MI period extent, the patients were more often used problem focused coping rather than emotion focused coping. The results of the present study can be related to other research studies, where they concluded that patients surviving after an MI, develop coping strategies related to their emotional state⁴⁰ and in another it was found out that, improvement in social support and adaptive coping strategies should be considered in patients with chronic ischemic heart disease (IHD) to reduce the risk of ACS⁴². But, in a Japanese population-based cohort⁴¹ study, they state that approach-oriented (problem focused) coping strategy, i.e. proactively dealing with sources of stress, may be associated with significantly reduced CVD mortality.

Section III: Assessment of samples based on their post-traumatic stress disorder after an acute MI

In the present study, 100 patients after acute myocardial infarction were selected as samples for the study. UKPTSS 14 scale was used to collect the data regarding post-traumatic stress disorder.

The present study results showed that mean percentage score of post-traumatic stress disorder was 27.15. The study results concluded that, 10% had PTSD and 27% of patients were have borderline PTSD symptoms. This study finding was consistent with the results of other research studies which showed that prevalence of myocardial infarction-related PTSD was 32%¹⁴, another showing 4% of the patients had PTSD³⁸ and 12% had partial PTSD, other study showing 9% had current PTSD¹², whereas around 14.8% had PTSD symptoms in three other studies^35,36,37 and in another 12% clinically significant symptoms of ACS-induced PTSD²⁰.

Section IV: Relationship between coping strategies and post-traumatic stress disorder among post MI patients.

In the present study 100 patients with acute myocardial infarction were selected as samples to assess the relationship between coping strategies and the development of post-traumatic stress disorder. Statistical analysis was done by using Pearson’s correlation test to identify the correlation between thecoping strategies and post-traumatic stress disorder.

The present study results revealed that among the domains of coping strategies, there is a moderate negative correlation (r = -0.385, p<0.05), exist between emotion focused coping strategies and post-traumatic stress disorder in samples with acute post myocardial infarction. These study findings were comparable with other research study in which researcher reported that 97 patients (82.2%) with MI who used emotion-focused coping strategy had negative perceived stress¹⁶, but contradictory to other in which they state thatreligious coping, which is an emotion focused coping strategy is positively related to depression⁴⁰.

The present study also showed that, there is aweak negative correlation (r = -0.204, p<0.05), exist between posttraumatic stress disorder and problem focused coping strategies. This study finding was contradictory with other research study which identified that, (53.6%) individuals who used problem-focused coping strategy sustained high level of stress¹⁶.

Data of the present study depicted that, there is a weak positive correlation (r = 0.280, p<0.05), between post-traumatic stress disorder and dysfunctional coping strategies. This result was congruent with other research studies, which showed that social withdrawal, which is a dysfunctional coping strategy was positively associated with PTSD symptoms⁴⁵ (r = .55 (.10); p<.001), another showing perceived consequences and dysfunctional coping were strongly associated with PTSD symptoms after controlling for MI and past history variables⁴⁷ and in otherbehavioural disengagement were positively related to depression⁴⁰. But the result in the present study is contradictory to another study in which they showed that using maladaptive coping strategies does not necessarily have a significant impact on PTSD symptoms⁴⁶.

Section V: Association between post-traumatic stress disorder and selected demographic and clinical data

Fischer’s exact test was used to find out the association between post-traumatic stress disorder with selected demographic variables like age, sex, education, occupation, religion, socio-economic status, type of family and marital status.

The present study revealed that there was no significant association between post-traumatic stress disorder with selected demographic and clinical variables age, sex, education, occupation, religion, socio-economic status, type of family and marital status. This finding is consistent with other research studies which proved that age, sex and the indicator of socioeconomic status (education and income) were not associated with PTSD or with PSS-SR scores^36,45.

The findings of the present study showed that there wasa significant association between post-traumatic stress disorder and no. of days of hospitalization [10.413 (p=0.036)]. This finding is contradictory when comparing with other research studies which revealed thatnone of the medical variables were significant³⁸.This may be due to the inclusion of samples in the present study, who had undergone surgery which could have contributed to the length of the hospital stay.

The present study also revealed that there was no significant association between post-traumatic stress disorder withclinical variables like type of treatment, family history of cardiovascular disease and no. of days of ICU stay. This finding is comparable with other research studies which revealed that none of the medical variables were significant³⁸.

CONCLUSION:

The present study was aimed to assess the relationship between coping strategies and development of post-traumatic stress disorder in patients after an acute myocardial infarction, in a selected hospital, Kottayam. The present study concluded that use of emotion focused and problem focused coping strategies can prevent the development of post-traumatic stress disorder among patients after an acute myocardial infarction.

LIMITATIONS:

· The study was limited to a small representative group of acute myocardial infarction patients.

· The data was gathered from only one setting, so the generalizability was limited.

· The samples include the patients who had underwent different treatment modalities, which can affect the stress levels.

NURSING IMPLICATIONS:

The study findings have implications in the field of nursing education, nursing service, nursing administration and nursing research.

Nursing service:

Nurses are the back bone of health care team. Nurses can assess the coping strategies used by the patients, development of post-traumatic stress disorder in patients after an acute myocardial infarction and the different coping strategies which can be used to prevent the occurrence of PTSD.

Nursing Education:

· The study results can be utilized by the nurse educators in preparing class on effectiveness of health education regarding assessment of different domains of coping strategies and its importance in promoting good coping abilities in patients after an acute MI.

Nursing Administration

· The finding of the study can help the nurse administrator to collaborate with the hospital authorities to formulate policies related to management after an acute MI, which should include prevention of PTSD and the different coping strategies used by them, which can be used to relieve stress.

· The nursing administrators can arrange and conduct workshops, conferences, and in-service education programs on the assessment of PTSD after MI and the effective coping strategies which can be used.

Nursing Research:

· The nurse researcher can undertake similar studies on assessment of development post-traumatic stress disorder and coping strategies among larger samples of acute myocardial infarction patients using different tools in the hospital.

· The nurse researcher can conduct a comparative study using variables like post-traumatic stress disorder and coping strategies with other chronic diseases such as, chronic renal failure, cancer, and stroke.

RECOMMENDATIONS:

Keeping in view the findings of the present study, the following recommendations have been made for the further study.

· A similar study can be replicated on a large sample with different demographic variables.

· An interventional study on predictors for post-traumatic stress disorder and usage of different coping strategies in patients after an acute MI.

· A quantitative study on effect of health education programme on improving coping skill in acute MI patients.

REFERENCES:

1. Upendra K, Vineet B. Perspective on coronary interventions & cardiac surgeries in India. Indian journal of medical research. PMC

2. Black MJ. Text book of medical surgical nursing. volume 2.8th edition. New Delhi: evolve; 2014

3. Thomas H, Michael S, John Williams. Functional status and quality of life in patients with heart failure undergoing coronary bypass surgery after assessment of myocardial viability. Elsevier; 1999

4. Emelia JB, Michael JB, Stephanie EC, Mary C. Heart Disease and Stroke Statistics-2017 Update: A Report from the American Heart Association. Circulation. 2017; 135(10): e146–e603.

5. Mozaffarian D, Benjamin EJ Executive Summary: Heart Disease and Stroke Statistics--2016 Update: A Report from the American Heart Association. Circulation. 2016; 133:447-54

6. T Sekhri,1 R S Kanwar,1 R Wilfred. Prevalence of risk factors for coronary artery disease in an urban Indian population. BMJ Open 2014; 4: e005346. DOI:10.1136/bmjopen-2014005346

7. Ahmed NM, Islam YE, and Carl JP. Prevalence, Causes, and Predictors of 30‐Day Readmissions Following Hospitalization with Acute Myocardial Infarction Complicated by Cardiogenic Shock: Findings from the 2013–2014 National Readmissions Database. Journal of the American Heart Association. vol. 7,6 e008235. 23 Mar. 2018,

8. Manyoo AA, Lohit G, Carl JL, Guy LR, Rami NK. Impact of family history of coronary artery disease on in-hospital clinical outcomes in ST-segment myocardial infarction. Ann Transl Med2018;6(1):3. Available from https:// www.researchgate. net/publication/322501105

9. Roland V K, Roman H, Jean-Paul S, Hugo S, Stefan B. Distress related to myocardial infarction and cardiovascular outcome: a retrospective observational study. BMC Psychiatry; 2011, 11:98. Available from http://www.biomedcentral.com/1471244X/11/98

10. Victoria S. Russell. Psychological care for patients with symptoms of myocardial infarction: a systematic review. Journal of nursing times. 2006; V102, Issue: 47, Page no: 34-35.

11. Anna M, Monika K, Monika S, Ryszard P. Psychological support for patients following myocardial infarction. Cardiology Journal 2010, Vol. 17, No. 3, pp. 319–324

12. Beth E, Charles R, Thomas C. Posttraumatic Stress Disorder and Health-Related Quality of Life in Patients with Coronary Heart Disease. American Medical Association;2009

13. Christian S, Klaus P. Health related quality of life and post-traumatic stress disorder in patients after cardiac surgery and intensive care treatment. Mosby; 2000

14. Jones RCM, Chung MC, Berger Z, Campbell JL. Prevalence of post-traumatic stress disorder in patients with previous myocardial infarction consulting in general practice. British Journal of General Practice; 2007; 57: 808–810.

15. Nicholas J, Devika B, Barbara O, Kerry J, Vasiliki M. Coping strategies as mediators in relation to resilience and posttraumatic stress disorder. Journal of Aﬀective Disorders. Elsevier

16. Seyed MSB, Nastaran A. A Survey of Coping Strategies with Stress in Patients with Acute Myocardial Infarction and Individuals Without a History of Fixed Myocardial Infarction. Journal of cardiology research. 2018 Feb; 9(1): 35–39. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819627/

17. Bimala P, Charuwan K, Tippamas C. Correlation between Coping Strategies and Quality of Life among Myocardial Infarction Patients in Nepal. Nurse Media Journal of Nursing, 1, 2, July 2011, 187- 194 187

18. Tulloch H, Greenman PS, Tassé V. Post-Traumatic Stress Disorder among Cardiac Patients: Prevalence, Risk Factors, and Considerations for Assessment and Treatment. Journal of Behaviour science; 2015; 5; 27–40;

19. World health organization. preventing chronic diseases: a vital investment. Geneva; 2005

20. Donald E, Safiya R, Louise F, Karina W. D, Mary A M, Yuval Neria. Posttraumatic Stress Disorder prevalence and risk of recurrence in Acute Coronary Syndrome Patients: A Meta-Analytic Review. PLoS ONE. June 2012 | Volume 7 | Issue 6 | e38915. Available from: www.plosone.org.

21. Bhagyalakshmi M, Venkata RB, Hema S, Jaya Mohan R. Assessment of the level of stress and coping strategies among patients with coronary artery disease. Journal of the Scientific Society, Vol 39 / Issue 3 / September-December 2012. Available from:http://www.jscisociety.com.

22. Krishnan M N, Zachariah G, Venugopal K, Mohanan P. Prevalence of coronary artery and its risk factors in Kerala, South India: a community based cross-sectional study. BMC cardiovascular disorders; 2016

23. Bincy R. Nursing Research. 2nd edition. Viva; 2013

24. Alligood RM, Tomey MA. Nursing theorists and their work. 7th edition. Mosby; 2010

25. Sharma SK. Nursing Research and statistics, 2nd ed. New Delhi: Elsevier;2011:104-105

26. Pramilaaa R. quality of life among post myocardial infarction patients. Nightingale nursing times. Volume 8, number 3, June 2012.

27. Lalitha K, Prabhudeva SS. Thandani N. Dharsan S. A correlative survey on stress and coping among post MI survivors. Nightingale nursing times. Volume 6, number 8, November 2010.

28. Fabian SG, Carme PQ, Roman L, Alejandro L. Epidemiology of coronary heart disease and acute coronary syndrome. Ann Transl Med 2016;4(13):256.

29. Jaber M, Toba K, Hossein B. A Systematic Review on the Prevalence of Acute Myocardial Infarction in Iran. Heart Views. 2017;18(4):125-132.

30. Shraddha C, Bani TA. Prevalence of cardiovascular disease in India and its economic impact- A review. International Journal of Scientific and Research Publications, Volume 3, Issue 10, October 2013 1 ISSN 2250-3153. Available from: http://www.ijsrp.org.

31. Mohammed VA, Farina Z, Shivani B, Kaushal K. A study of risk factors in young patients of myocardial infarction. International Journal of Research in Medical Sciences. 2015 Oct;3(10):2677-2681. Available from: www.msjonline.org

32. Raihanathul M, N Sudhayakumar, S Abdul Khadar, Raju G, VL Jayaprakash, Joseph MP. The Clinical Spectrum of Acute Coronary Syndromes: Experience from a Major Centre in Kerala. JAPI. May 2009; Vol. 57. Available from: https://pdfs.semanticscholar.org/4019/df2eef763b809fb37ac30c4612f35466fb50.pdf

33. Matthew MB, Robert S. Post-traumatic Stress Disorder and Cardiovascular Disease. CurrCardiol Rep (2016) 18: 94. Available from: https://www.researchgate.net/publication/307091976.

34. Donald E, Nina R, Jonathan AS, Joseph ES, Matthew MB, Karina W. D, Lynn C, Daichi S, Ian MK. Posttraumatic stress due to an acute coronary syndrome increases risk of 42-month major adverse cardiac events and all-cause mortality. Journal of Psychiatry research 2011 December; 45(12):1621–1626.

35. D L Whitehead, L Perkins-Porras, P C Strike, A Steptoe. Post-traumatic stress disorder in patients with cardiac disease: predicting vulnerability from emotional responses during admission for acute coronary syndromes. Heart 2006; 92:1225–1229.

36. Marie LG, Roland K. Myocardial infarction and post-traumatic stress disorder: frequency, outcome, and atherosclerotic mechanisms. European Journal of Cardiovascular Prevention and Rehabilitation 2006, 13:165–172

37. M-A Roberge, G Dupuis, A Marchand. Post-traumatic stress disorder following myocardial infarction: Prevalence and risk factors. Journal of Cardiology; 2010;26(5): e170-e175.

38. Mari ST, Paivi AK, Matti R, Eija P. Coping Experiences: A Pathway towards Different Coping Orientations Four and Twelve Months after Myocardial Infarction-A Grounded Theory Approach. Nursing Research and Practice Volume 2012, Article ID 674783, 9 pages. Available from: https://www.hindawi.com/ journals/nrp/2012/674783/

39. Maria C, Sophia-A M. Coping and emotional state in the acute phase of myocardial infarction. Aristotle University Medical Journal, Vol. 42, Issue 2, June 2015. Available from: http://ejournals.lib.auth.gr/aumj/article/viewFile/4645/4747

40. Thomas S, Manami I. Coping strategies and risk of cardiovascular disease incidence and mortality: The Japan Public Health Centre-based prospective Study. European Heart Journal (2016) 37, 890–899

41. Hamidreza R, Mohammad T. Association of social support and coping strategies with acute coronary syndrome: A case—control study. Journal of Cardiology (2012) 59, 154—159. Available from: www.elsevier.com/locate/jjcc.

42. Mona S. Myocardial infarction personality factors, coping strategies, depression and secondary prevention. Faculty of Health and Society. Malmö University, 2016. Available from:http://muep.mau.se/bitstream/handle/2043/20214/HS_2016.1

43. Ajaz AK, Mudassir H, Pradeep K, Mishra D, Ranjeet K. Personality Profile and Coping Skills among Coronary Heart Disease Patients and Non-Patient Groups. Delhi Psychiatry Journal 2012; 15:(2)

44. Nicholas JT, Devika F, Barbara OR, Kerry JR, Vasiliki M. Coping strategies as mediators in relation to resilience and posttraumatic stress disorder. Journal of Aﬀective Disorders. Elsevier; 225 (2018) 153–159

45. Chung MC, Berger Z, Rudd H. Coping with posttraumatic stress disorder and comorbidity after myocardial infarction. Journal of Comprehensive Psychiatry. Volume 49, Issue 1, January–February 2008, Pages 55-64. Available from: https://DOI.org/10.1016/ j.comppsych.2007.08.003

46. Ayers S, Copland C, Dunmore E. A preliminary study of negative appraisals and dysfunctional coping associated with post-traumatic stress disorder symptoms following myocardial infarction. British Journal of Health Psychology. 2009 Sep;14(Pt 3):459-71.

Received on 26.09.2020 Modified on 29.10.2020

Asian J. Nursing Education and Research. 2021; 11(2):271-278.

DOI: 10.5958/2349-2996.2021.00065.3