Predictors of attendance at cardiac rehabilitation after myocardial infarction

Patients' beliefs about the causes, persistence and control of psychotic experiences predict take-up of effective cognitive behaviour therapy for psychosis

BACKGROUND

There is evidence that patients with schizophrenia benefit from standard cognitive behaviour therapy (CBT) only if active techniques are used ('full therapy'). By contrast, attending sessions but not proceeding beyond engagement and assessment strategies ('partial therapy'), or simply not attending sessions ('no therapy'), is not associated with better outcomes. The factors leading to full therapy are unknown. We hypothesized that patients' initial ideas about the nature and extent of their problems would predict use of CBT. A match between patients' views of their problems and the principles underlying treatment would lead to better outcomes.

METHOD

Ninety-two patients with a recent relapse of psychosis completed the Illness Perception Questionnaire (IPQ) before receiving CBT. We examined whether their illness perceptions predicted the take-up of therapy.

RESULTS

Patients who did not attend sessions believed their problems would not last as long as those who attended them. Those who attended sessions but did not proceed to full therapy had a lower sense of control over their problems and a more biological view of their causes. Patients who took up full therapy were more likely to attribute the cause of their problems to their personality and state of mind. The take-up of therapy was predicted neither by levels of psychiatric symptoms nor by insight.

CONCLUSIONS

People with psychosis who have psychologically orientated views of their problems, including the potential to gain control over them, may be more likely to engage fully and do well with standard CBT for psychosis, irrespective of the severity of their problems.

A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change

BACKGROUND

Healthy lifestyles are an important facet of cardiovascular risk management. Unfortunately many individuals fail to engage with lifestyle change programmes. There are many factors that patients report as influencing their decisions about initiating lifestyle change. This is challenging for health care professionals who may lack the skills and time to address a broad range of barriers to lifestyle behaviour. Guidance on which factors to focus on during lifestyle consultations may assist healthcare professionals to hone their skills and knowledge leading to more productive patient interactions with ultimately better uptake of lifestyle behaviour change support. The aim of our study was to clarify which influences reported by patients predict uptake and completion of formal lifestyle change programmes.

METHODS

A systematic narrative review of quantitative observational studies reporting factors (influences) associated with uptake and completion of lifestyle behaviour change programmes. Quantitative observational studies involving patients at high risk of cardiovascular events were identified through electronic searching and screened against pre-defined selection criteria. Factors were extracted and organised into an existing qualitative framework.

RESULTS

374 factors were extracted from 32 studies. Factors most consistently associated with uptake of lifestyle change related to support from family and friends, transport and other costs, and beliefs about the causes of illness and lifestyle change. Depression and anxiety also appear to influence uptake as well as completion. Many factors show inconsistent patterns with respect to uptake and completion of lifestyle change programmes.

CONCLUSION

There are a small number of factors that consistently appear to influence uptake and completion of cardiovascular lifestyle behaviour change. These factors could be considered during patient consultations to promote a tailored approach to decision making about the most suitable type and level lifestyle behaviour change support.

Cardiac rehabilitation and exercise therapy in the elderly: Should we invest in the aged?

Coronary heart disease (CHD) is the leading cause of death worldwide and becomes increasingly prevalent among patients aged 65 years and older. Elderly patients are at a higher risk for complications and accelerated physical deconditioning after a cardiovascular event, especially compared to their younger counterparts. The last few decades were privy to multiple studies that demonstrated the beneficial effects of cardiac rehabilitation (CR) and exercise therapy on mortality, exercise capacity, psychological risk factors, inflammation, and obesity among patients with CHD. Unfortunately, a significant portion of the available data in this field pertains to younger patients. A viable explanation is that older patients are grossly underrepresented in these programs for multiple reasons starting with the patient and extending to the physician. In this article, we will review the benefits of CR programs among the elderly, as well as some of the barriers that hinder their participation.

Socially differentiated cardiac rehabilitation: can we improve referral, attendance and adherence among patients with first myocardial infarction?

AIM

The comprehensive cardiac rehabilitation (CR) programme after myocardial infarction (MI) improves quality of life and results in reduced cardiac mortality and recurrence of MI. Hospitals worldwide face problems with low participation rates in rehabilitation programmes. Inequality in recruitment and participation among low educated and socially vulnerable patients must be addressed to lower inequality in post-MI health. Our aim was to improve referral, attendance, and adherence rates among socially vulnerable patients by systematic screening and by offering a socially differentiated cardiac rehabilitation programme.

METHODS

From 1 September 2002 to 31 December 2005, 388 first-incidence MI patients ≤75 years were hospitalised. Register check for newly hospitalised MI patients, screening interview, and systematic referral were conducted by a project nurse. Patients were referred to a standard rehabilitation programme (SRP). If patients were identified as socially vulnerable, they were offered an extended version of the rehabilitation programme (ERP). Excluded patients were offered home visits by a cardiac nurse. Concordance principles were used in the individualised programme elements. Adherence was registered until the 1-year follow up.

RESULTS

86% were referred to the CR. A large share of elderly patients and women were excluded. The attendance and adherence rates were 80% and 71%, respectively among all hospitalised patients. Among referred patients, the attendance rate was 93%. Patients were equally distributed to the SRP and the ERP. No inequality was found in attendance and adherence among referred patients.

CONCLUSIONS

It seems possible to overcome unequal referral, attendance, and adherence in cardiac rehabilitation by organisation of systematic screening and social differentiation.

Assessing acute coronary syndrome patients' cardiac-related beliefs, motivation and mood over time to predict non-attendance at cardiac rehabilitation

AIM

This research protocol describes and justifies a study to assess patients' cardiac-related beliefs (i.e. illness representations, knowledge/misconceptions, cardiac treatment beliefs), motivation and mood over time to predict non-attendance at a cardiac rehabilitation programme by measuring weekly/monthly changes in these key variables.

BACKGROUND

Heart disease is the UK's leading cause of death. Evidence from meta-analyses suggests that cardiac rehabilitation facilitates recovery following acute cardiac events. However, 30-60% of patients do not attend cardiac rehabilitation. There is some evidence from questionnaire studies that a range of potentially modifiable psychological variables including patients' cardiac-related beliefs, motivation and mood may influence attendance.

DESIGN

Mixed-methods.

METHODS

In this study, during 2012-2013, electronic diary data will be gathered weekly/monthly from 240 patients with acute coronary syndrome from discharge from hospital until completion of the cardiac rehabilitation programme. This will identify changes and interactions between key variables over time and their power to predict non-attendance at cardiac rehabilitation. Data will be analysed to examine the relationship between patients' illness perceptions, cardiac treatment beliefs, knowledge/misconceptions, mood and non-attendance of the cardiac rehabilitation programme. The qualitative component (face-to-face interviews) seeks to explore why patients decide not to attend, not complete or complete the cardiac rehabilitation programme.

DISCUSSION

The identification of robust predictors of (non-)attendance is important for the design and delivery of interventions aimed at optimizing cardiac rehabilitation uptake. Funding for the study was granted in February 2011 by the Scottish Government Chief Scientist Office (CZH/4/650).

The Predictive Value of ΣΔST/ΔHR Index for Restenosis after Percutaneous Coronary Intervention

Objective

To find out the predictive value of the ΣΔST/ΔHR index for restenosis after percutaneous coronary intervention (PCI).

Method

Subjects of this research were patients who participated in a cardiac rehabilitation (CR) program as six to eight weeks of a hospital-based program after receiving PCI to treat acute coronary syndrome (ACS). The patients received coronary angiography (CAG) at the onset of the ACS and nine months after that, and also received an exercise tolerance test (ETT) at the start of the CR program and several days before receiving a follow-up CAG. In ETT, we used the sum of the ST depression (ΣΔST index) of leads II, III, aVF, V_4-6 as well as the sum of the ΔST/ΔHR (heart rate) (ΣΔST/ΔHR index) in the same leads and the sum of the ΔST/ΔRPP (rate pressure product) (ΣΔST/ΔRPP index) in the same leads. We compared the predictive power of each index of ETT for restenosis after PCI.

Results

The sensitivity, specificity, positive predictive value, and negative predictive value of ΣΔST index were 69%, 47%, 31%, and 82%. The ΣΔST/ΔHR index was 13.7±5.2 in the restenosis group and 9.3±5.6 in the patent group (p=0.017). The sensitivity, specificity, positive predictive value, and negative predictive value of this index were 85%, 63%, 44%, and 92%. The ΣΔST/ΔRPP index were 0.10±0.08 in the restenosis group and 0.06±0.04 in the patent group (p=0.016). The sensitivity, specificity, positive predictive value, and negative predictive value of this index were 54%, 76%, 44%, and 83%.

Conclusion

The ΣΔST/ΔHR index showed a much higher sensitivity and negative predictive value for restenosis after PCI compared to the ΣΔST index.

Cardiac rehabilitation participation in underserved populations. Minorities, low socioeconomic, and rural residents

Cardiac rehabilitation (CR) services in the United States are underutilized and participation is particularly low for racial and ethnic minorities, low socioeconomic status patients, and rural residents. Reduced participation may not only indicate a failure in transitional cardiac care during the in hospital referral process but also could be due to barriers attributed to patients, providers, employers, or medical systems. In-depth analysis of this problem is impeded by difficulties with the identification of underserved groups in clinical settings. Disparities in CR participation certainly contribute to poor medical outcomes in these populations that stand to benefit greatly from lifestyle modifications. It is critical that CR providers survey their communities for underserved populations and coordinate creative efforts aimed at overcoming barriers to participation. Moreover, it is likely that referral to, and participation in, CR will soon be considered a quality indicator, providing further incentive for programs to optimize CR utilization among all eligible patients.

Gender differences in recovery goals in patients after acute myocardial infarction

PURPOSE

: While cardiac rehabilitation has been established as an essential part of comprehensive cardiac care, participation rates for female patients are substantially lower than for male patients. Lower referral rates and higher ages of female patients partly explain this underutilization. Gender differences in recovery goals of cardiac patients have not been examined.

METHODS

: Five hundred ninety patients (22.2% women) admitted to the hospital because of an acute myocardial infarction answered a questionnaire regarding 24 goals in 5 domains of recovery (physical functioning, risk-factor modification, psychological well-being, independence in daily life, and return to work). In addition, psychological symptoms and medical data were assessed. Gender differences were tested by using χ and Student t tests, as well as multivariate logistic and linear regression models.

RESULTS

: Gender differences were found in 7 of the 24 recovery goals. After adjustment for psychosocial and clinical characteristics, women still reported a higher importance of "performance of household duties" (odds ratio [OR] = 8.62; 95% confidence interval [CI], 5.43-13.66), "independence in activities of daily living" (OR = 2.38; CI, 1.58-3.59), and "emotional equilibrium" (OR = 1.58, CI, 1.01-2.46). Men rated "physical endurance" and "reducing strain at workplace" as more important goals (OR = 0.64; CI, 0.42-0.97 and OR = 0.39; CI, 0.17-0.93). Except for psychological distress, gender differences in health status were not related to differences in goals.

CONCLUSIONS

: Gender roles and differences in social-life conditions may have an important influence on the recovery goals of patients after an acute myocardial infarction. Recovery goals should be explored when planning intervention programs for individual patients.

Relationship of persistent symptoms of anxiety to morbidity and mortality outcomes in patients with coronary heart disease

OBJECTIVE

To examine the association of symptoms of persistent anxiety with the development of acute cardiac events in patients with coronary heart disease (CHD) followed for 2 years. The prevalence of symptoms of anxiety is high in patients with CHD, but their effect on cardiac events and mortality has not been well characterized.

METHODS

Of 3522 patients with confirmed CHD enrolled, data on symptoms of anxiety were available at two time points in 3048 patients who were then followed up for detection of the composite end point of hospitalization for myocardial infarction, unstable or stable angina, other cardiac causes, or all-cause mortality. A composite anxiety symptoms score composed of baseline and 3-month anxiety data, in which the continuous-level scores were used, was tested using Cox proportional hazards regression model. Groups (persistent anxiety [anxiety at both time points] versus nonanxious [no anxiety at either time point] versus not persistently anxious [anxiety only at one time point]) were also compared.

RESULTS

Symptoms of persistent anxiety, whether considered as a continuous- or categorical-level variable, were associated with shorter time to event. Persistent anxiety remained as an independent predictor of the end point after controlling for multiple variables (persistent anxiety as a summary score [hazard ratio = 1.27, 95% confidence interval = 1.067-1.514] and persistent anxiety as a categorical variable [hazard ratio = 1.52, 95% confidence interval = 1.149-2.015]).

CONCLUSIONS

By measuring anxiety symptoms at more than one time point and controlling for relevant sociodemographic, comorbidity, risk factor, and psychological covariates, we illustrate that symptoms of persistent anxiety are a strong, independent predictor of cardiac event-free survival.

Depression and failure of cholesterol lowering after acute myocardial infarction

OBJECTIVE

Depression after acute myocardial infarction (MI) is independently associated with cardiac mortality, but the mechanism explaining this association remains unclear. To our knowledge, there has been no prior study exploring the impact of post-MI depression on lipid lowering, a key secondary prevention measure in post-MI patients. In this prospective observational cohort pilot study, we hypothesized that patients with early post-MI depression would have inferior cholesterol reduction 6 months post-MI compared to nondepressed patients.

METHOD

Patients admitted to a cardiac intensive care unit or a cardiac step-down unit between October 2003 and July 2005 were enrolled in the study within 72 hours of MI. Two weeks post-MI, subjects were assessed for depression using the module for current major depressive disorder (MDD) from the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) and the Beck Depression Inventory-II (BDI-II). Information regarding cholesterol levels was collected 6 months after MI.

RESULTS

Initial and 6-month cholesterol levels were available for 70 subjects who had 2-week post-MI depression assessments. Post-MI depression, measured both using an interview for MDD and the BDI-II, was associated with inferior cholesterol reduction, with depressed subjects improving their cholesterol levels by approximately 8 mg/dL compared to a cholesterol reduction of 37 mg/dL in nondepressed subjects. Furthermore, depression diagnosed by formal MDD interview (beta=-.301; P<.001) and the BDI-II (beta=-.269; P=.001) continued to be associated with significantly smaller reductions in cholesterol levels on linear regression analyses that accounted for demographic and medical variables.

CONCLUSIONS

In this exploratory pilot study, early post-MI depression was independently associated with impaired lipid lowering 6 months after MI.

The effect of a self exercise program in cardiac rehabilitation for patients with coronary artery disease

OBJECTIVE

To investigate the effect of self exercise in cardiac rehabilitation on cardiopulmonary exercise capacity for selected patients with coronary artery disease.

METHOD

The subjects of this study were patients who received percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) surgery and who participated in a cardiac rehabilitation program. The supervised exercise group participated in 6-8 weeks of aerobic exercise training with telemetry ECG monitoring in hospital. The self exercise group, whose exercise risk was low, was instructed to participiate in self exercise training in a community exercise environment according to the exercise tolerance test (ETT) using a modified Bruce protocol. Both groups underwent ETTs before and 6 months after initiation of the cardiac rehabilitation program. We compared the supervised group with the self exercise groups on exercise capacity.

RESULTS

After 6 months, the supervised exercise group showed significant changes in maximum oxygen consumption, maximal heart rate, resting heart rate, and submaximal rate pressure product. The self exercise group also showed significant improvement of maximum oxygen consumption and submaximal rate pressure product. However, the changing rate of maximum oxygen consumption was significantly higher in the supervised exercise group than the self exercise group.

CONCLUSION

Both the supervised and self exercise groups showed similar improvement of cardiopulmonary exercise capacity after 6 months' participation in the cardiac rehabilitation program. However, the changing rate of maximum oxygen consumption, maximal heart rate, and resting heart rate were significantly higher in the supervised exercise group than the self exercise group.

Mediterranean diet mediates the adverse effect of depressive symptomatology on short-term outcome in elderly survivors from an acute coronary event

Aims. We evaluated the interaction effect between depressive symptoms and dietary habits on 30-day development of cardiovascular disease (CVD) (death or rehospitalization) in elderly, acute coronary syndrome (ACS) survivors. Methods. During 2006-2008, we recorded 277 nonfatal, consecutive ACS admissions (75 ± 6 years, 70% males, 70% had diagnosis of myocardial infarction) with complete 30-day follow-up. Assessment of recent depressive symptoms was based on the CES-D scale. Among sociodemographic, bioclinical, lifestyle characteristics, the MedDietScore that assesses the inherent characteristics of the Mediterranean diet was applied. Results. 22% of the ACS pts developed a CVD event during the first 30 days (14.8% rehospitalization and 9.4% death). Patients in the upper tertile of the CES-D scale (i.e., >18) had higher incidence of CVD events as compared with those in the lowest tertile (21% versus 8%, P = .01). Multiple logistic regression analysis revealed that 1-unit increase in CES-D was associated with 4% higher odds (95% CI 1.008-1.076, P = .01) of CVD events; however, when MedDietScore was entered in the model, CES-D lost its significance (P = .20). Conclusion. Short-term depressive symptoms are related to a worsen 30-day prognosis of ACS patients; however, this relationship was mediated by Mediterranean diet adherence.

Adoption of community-based cardiac rehabilitation programs and physical activity following phase III cardiac rehabilitation in Scotland: a prospective and predictive study

Little is known about levels of physical activity and attendance at phase IV community-based Cardiac Rehabilitation (CR) programs following completion of exercise-focussed, hospital-based phase III CR. This study aims to test, compare and combine the predictive utility of the Common-Sense Self-Regulation Model (CS-SRM) and the extended Theory of Planned Behaviour (TPB) with action planning for two rehabilitation behaviours: physical activity and phase IV CR attendance. Individuals diagnosed with coronary heart disease (n = 103) completed baseline measures of illness perceptions, intentions, perceived behavioural control (PBC), action planning and past physical activity in the last week of a phase III CR program, and 95 participants completed follow-up measures of physical activity and attended phase IV CR (objectively confirmed) 2 months later. Only one predictor (PBC/cyclical timeline) significantly predicted levels and change of physical activity. While illness perceptions were not predictive of phase IV CR attendance, the extended TPB model showed good predictive power with action planning and intention as the most powerful predictors. Amongst participants who planned when and where to attend phase IV CR at the end of phase III rehabilitation, 65.9% subsequently attended a phase IV CR program compared to only 18.5% of those who had not made a plan. This study adds to our understanding of cardiac rehabilitation behaviour after completion of health service delivered programs. Comparing theoretical models and rehabilitation behaviours contributes to the development of behaviour theory.

The relationship between depression, anxiety, and cardiovascular outcomes in patients with acute coronary syndromes

Depression and anxiety occur at high rates among patients suffering an acute coronary syndrome (ACS). Both depressive symptoms and anxiety appear to adversely affect in-hospital and long term cardiac outcomes of post-ACS patients, independent of traditional risk factors. Despite their high prevalence and serious impact, mood and anxiety symptoms go unrecognized and untreated in most ACS patients and such symptoms (rather than being transient reactions to ACS) persist for months and beyond. The mechanisms by which depression and anxiety are linked to these negative medical outcomes are likely a combination of the effects of these conditions on inflammation, catecholamines, heart rate variability, and endothelial function, along with effects on health-promoting behavior. Fortunately, standard treatments for these disorders appear to be safe, well-tolerated and efficacious in this population; indeed, selective serotonin reuptake inhibitors may actually improve cardiac outcomes. Future research goals include gaining a better understanding of the combined effects of depression and anxiety, as well as definitive prospective studies of the impact of treatment on cardiac outcomes. Clinically, protocols that allow for efficient and systematic screening, evaluation, and treatment for depression and anxiety in cardiac patients are critical to help patients avoid the devastating effects of these illnesses on quality of life and cardiac health.

Broken-Hearted Women: The Complex Relationship between Depression and Cardiovascular Disease

The importance of mind–body health relationships has been recognized for decades, but only recently has the wider medical and cardiovascular community become engaged in understanding and addressing the complex, bidirectional risk relationship between cardiovascular disease (CVD) and depression. Furthermore, it has become increasingly clear that there are incompletely understood sex differences in incidence and outcomes for both conditions that should guide treatment and future research efforts. This review will explore the role of depression in women as a risk factor for incident CVD, its impact on women already suffering from CVD, proposed psychobiologic mechanisms and links, and the implications of sex differences on diagnosis and treatment.

Barriers to participation in cardiac rehabilitation

BACKGROUND

Participation rates in cardiac rehabilitation after myocardial infarction (MI) remain low. Studies investigating the predictive value of psychosocial variables are sparse and often qualitative. We aimed to examine the demographic, clinical, and psychosocial predictors of participation in cardiac rehabilitation after MI in the community.

METHODS

Olmsted County, Minnesota, residents hospitalized with MI between June 2004 and May 2006 were prospectively recruited, and a 46-item questionnaire was administered before hospital dismissal. Associations between variables and cardiac rehabilitation participation were examined using logistic regression.

RESULTS

Among 179 survey respondents (mean age 64.8 years, 65.9% male), 115 (64.2%) attended cardiac rehabilitation. The median (25th-75th percentile) number of sessions attended within 90 days of MI was 13 (5-20). Clinical characteristics associated with rehabilitation participation included younger age (odds ratio [OR] 0.95 per 1-year increase), male sex (OR 1.93), lack of diabetes (OR 2.50), ST-elevation MI (OR 2.63), receipt of reperfusion therapy (OR 7.96), in-hospital cardiologist provider (OR 18.82), no prior MI (OR 4.17), no prior cardiac rehabilitation attendance (OR 3.85), and referral to rehabilitation in the hospital (OR 12.16). Psychosocial predictors of participation included placing a high importance on rehabilitation (OR 2.35), feeling that rehabilitation was necessary (OR 10.11), better perceived health before MI (excellent vs poor OR 7.33), the ability to drive (OR 6.25), and post-secondary education (OR 3.32).

CONCLUSIONS

Several clinical and psychosocial factors are associated with decreased participation in cardiac rehabilitation programs after MI in the community. As many are modifiable, addressing them may improve participation and outcomes.

Cardiovascular abnormalities in patients with major depressive disorder: autonomic mechanisms and implications for treatment

This article provides a detailed review of the association of major depression with coronary heart disease (CHD), examines the biological variables underpinning the linkage and discusses the clinical implications for treatment. When considering the co-morbidity between major depressive disorder (MDD) and CHD it is important to differentiate between (i) the prevalence and impact of MDD in those with existing CHD and (ii) MDD as a risk factor for the development of CHD. Whether the same biological mechanisms are at play in these two instances remains unknown. Depression is common in patients with CHD. Importantly, depression in these patients increases mortality. There is also consistent evidence that MDD is a risk factor for the development of CHD. The relative risk of developing CHD is proportional to the severity of depression and is independent of smoking, obesity, hypercholesterolaemia, diabetes mellitus and hypertension. There is a clear need to identify the underlying neurochemical mechanisms responsible for MDD and their linkage to the heart and vascular system. Of particular interest are activation of stress pathways, including both the sympathetic nervous system and hypothalamic-pituitary-adrenal axis, and inflammatory-mediated atherogenesis. Elevated sympathetic activity, reduced heart rate variability and increased plasma cortisol levels have been documented in patients with MDD. In addition to direct effects on the heart and vasculature, activation of stress pathways may also be associated with increased release of inflammatory cytokines such as interleukin-6 and tumour necrosis factor-alpha. Elevated levels of C-reactive protein are commonly observed in patients with MDD. The majority of investigations examining treatment of depression following myocardial infarction have focused on safety and efficacy; there is little evidence to indicate that treating depression in these patients improves survival. Given that strategies for preventive therapy remain incompletely formulated, future research should focus on generating a better understanding of the neurobiology of MDD and heart disease as a basis for rational and effective therapy.

Relation of anxiety and adherence to risk-reducing recommendations following myocardial infarction

Unlike depression, the relation between anxiety and the adherence to risk-reducing recommendations after myocardial infarction (MI) has not been well studied. The aim of this study was to explore the effect of anxiety on adherence after MI. Patients (n = 278) hospitalized for MI were assessed for anxiety using the Beck Anxiety Inventory during the hospitalization (baseline) and at 4 months of follow-up. The measures of adherence included following a low-sodium, low-fat diet, exercising regularly, taking medications, decreasing stress, carrying medical supplies, increasing socialization, following a diabetic diet, measuring blood glucose levels, and smoking cessation (where applicable). Baseline anxiety was associated with younger age, female gender, hypertension, tobacco use, depression, and current mood disorder. At 4 months of follow-up, anxiety was also associated with living alone, a history of coronary artery disease, and Killip class >1. An anxiety summary score was calculated to assess anxiety across both points. Summary anxiety was associated with worse adherence to exercise, reducing stress, increasing socialization, and smoking cessation but with better adherence to carrying supplies (all p <0.05). After controlling for demographic, cardiovascular, and psychological factors, summary anxiety predicted worse adherence to reducing stress (p = 0.004) and increasing socialization (p = 0.033) and was the only significant predictor of worse adherence to smoking cessation (p = 0.001) and better adherence to carrying supplies (p = 0.04). Anxiety during the initial hospitalization and 4 months later was associated with lower adherence to many important risk-reducing recommendations after MI. In conclusion, additional research is needed to evaluate whether treating anxiety can improve adherence in this setting.

Marital status and cardiac rehabilitation attendance: a meta-analysis

BACKGROUND

Marital status has been clearly linked to subsequent health outcomes in those with established coronary heart disease (CHD). This robust association may be because of both pathophysiological and behavioural mechanisms.

DESIGN

We employed meta-regression to examine the association between marital status and attendance at outpatient cardiac rehabilitation (CR) in published studies.

METHODS

We searched electronic databases, for example, Medline and Science Citation Index, for published studies that reported an association between a measure of marital or partnered status and CR attendance in patients with diagnosed CHD.

RESULTS

Eleven studies were identified which incorporated 6,984 CHD patients. Being married/partnered was associated with significantly higher odds of attending CR. Using a fixed effects model, the pooled odds ratio of CR attendance was 1.72 [95% confidence interval (CI) 1.50-1.97] for those who were married/partnered. There was no evidence of heterogeneity of effects (P=0.42) or publication bias (P=0.12).

CONCLUSION

CHD patients who are married or have a partner are between 1.5-2 times more likely to attend CR. Associations between marital status and CR attendance may partly explain CHD outcomes.

Depression in patients with coronary heart disease

Approximately 20% of patients with coronary heart disease (CHD) have major depression and 20% have minor depression at any given point in the course of their illness. Depression causes significant psychological and social morbidity, and is a risk factor for further cardiac morbidity and mortality. Although there are many possible biological and behavioral mechanisms, the causal pathways through which depression increases the risk for cardiac events and death are not well understood. Despite the morbidity associated with depression, and the devastating impact it has on the quality of life of patients with CHD, it is underdiagnosed and often left untreated. This article describes screening techniques for use in primary care and cardiology settings, and discusses the safety and efficacy of available treatments for depression in patients with CHD.

Development and preliminary testing of the Cardiac Rehabilitation Enrolment Obstacles (CREO) scale: implications for service development

BACKGROUND

In spite of the benefit in participating in cardiac rehabilitation (CR) programs, low participation rates are well documented. Participation rates are potentially lower in people who have undergone percutaneous coronary interventions (PCI). Assessment of the barriers to CR participation in PCI patients could provide vital information for the development of alternate strategies for coronary risk factor modification.

AIM

The aim of this study was to develop and evaluate the psychometric properties of a scale to assess obstacles to cardiac rehabilitation enrolment in patients following PCI.

METHODS

Item generation for the 15 items of this scale was based on a comprehensive review of the literature and data collected from telephone interviews of CR coordinators related to cardiac rehabilitation enrolment obstacles (CREO). Content validity of the scale was undertaken using a reference group comprising of clinicians and patients. Construct validity was undertaken using a factor analysis. Data for the CREO scale was collected from December 2004 to March 2005 from 114 PCI patients recruited from a cardiology database in a Sydney metropolitan hospital.

RESULTS

Factor analysis revealed a two-factor structure: patient-related obstacles and health service-related obstacles, which accounted for 58% of cumulative explained variance. The scale showed good internal consistency (Cronbach's alpha=0.89) and satisfactory divergent validity.

CONCLUSION

This scale can be used as a useful tool for the early identification of patients who would not normally enrol into CR and offer them alternate strategies for health-related lifestyle modification.

“The Rust of Life”: Impact of Anxiety on Cardiac Patients

Anxiety has both functionally appropriate and inappropriate consequences. Among patients with cardiac disease, anxiety can be functionally appropriate when it prompts an individual to quickly seek treatment for acute cardiac signs and symptoms. But anxiety may have medical or psychological consequences when it is persistent or severe, including difficulty adhering to prescribed treatments and making recommended lifestyle changes, adoption of or failure to change risky behaviors, increased risk for acute cardiac events, and increased risk for in-hospital complications after admission for acute coronary syndrome. Yet, because anxiety is a universal emotion that is managed without consequence by many people, its importance is often ignored by healthcare providers. The impact of psychosocial (with a major emphasis on anxiety) and behavioral variables on biological outcomes was examined systematically. The research included (1) examination and comparison of the intensity of anxiety in international samples of various critically, acutely, and chronically ill cardiac patients; (2) determination of differences between men and women in the expression of anxiety; (3) investigation of factors predictive of anxiety levels, including perceived control; (4) studies of healthcare providers’ knowledge of anxiety assessment and providers’ practices in assessing and managing anxiety; and (5) determination of the impact of anxiety on clinical outcomes in cardiac patients. The goal of this program of research is to improve patients’ outcomes on a widespread basis by placing anxiety in the forefront of clinical cardiac practice.

Predictors of drop-out from an outpatient cardiac rehabilitation programme

OBJECTIVE

To investigate the prevalence and predictors of early drop-out from a cardiac rehabilitation programme and also whether completers and drop-out patients differed in relation to their illness cognitions, gender and psychological distress and quality of life.

DESIGN

A six-week outpatient cardiac rehabilitation programme.

SETTING

A university teaching hospital.

SUBJECTS

One hundred and eighty-nine patients were recruited from a consecutive series of outpatient referrals prior to a six-week comprehensive cardiac rehabilitation programme.

OUTCOME MEASURES

The revised Illness Perception Questionnaire, Quality of Life after Myocardial Infarction Questionnaire and the Hospital Anxiety and Depression Scale.

RESULTS

One hundred and forty-seven cardiac patients completed the cardiac rehabilitation programme. Forty-two (22%) patients dropped out in the first two weeks. Factors predicting early drop-out were female gender, younger age, higher Hospital Anxiety Depression Scale score, lower illness perception consequences and higher illness perception personal control and lower illness perception treatment control (all P < 0.05).

CONCLUSION

Over a fifth of the patients did not complete this typical cardiac rehabilitation programme. Female patients are more likely to drop out from cardiac rehabilitation than men. Psychological distress, younger age and lower perceptions of consequences, higher perception personal control and lower illness perception of treatment control were predictors of early drop-out from a cardiac rehabilitation programme.

Effects of antidepressant treatment following myocardial infarction

BACKGROUND

Depression following myocardial infarction is associated with poor cardiac prognosis. It is unclear whether antidepressant treatment improves long-term depression status and cardiac prognosis.

AIMS

To evaluate the effects of antidepressant treatment compared with usual care in an effectiveness study.

METHOD

In a multicentre randomised controlled trial, 2177 myocardial infarction patients were evaluated for ICD-10 depression and randomised to intervention (n=209) or care as usual (n=122). Both arms were evaluated at 18 months post-myocardial infarction for long-term depression status and new cardiac events.

RESULTS

No differences were observed between intervention and control groups in mean scores on the Beck Depression Inventory (11.0, s.d.=7.5 v.10.2, s.d.=5.1, P=0.45) or presence of ICD-10 depression (30.5 v. 32.1%, P=0.68). The cardiac event rate was 14% among the intervention group and 13% among controls (OR=1.07, 95% CI 0.57-2.00).

CONCLUSIONS

Antidepressant treatment did not alter long-term depression post-myocardial infarction status or improve cardiac prognosis.

Depression in patients with acute myocardial infarction: Influence on autonomic nervous system and prognostic role. Results of a five-year follow-up study

BACKGROUND

Although previous studies demonstrated an association between depressive symptoms and cardiac mortality after acute myocardial infarction (AMI) little is known about the possible mechanisms of this association. The aim of this study was to determine whether depressed patients present a cardiac autonomic dysfunction and whether this could represent the mediator of the influence of depression on their prognosis.

METHODS

One hundred consecutive patients with AMI were recruited between January and December 1999. Major Depressive Disorder (MDD) was diagnosed by structured clinical interview and the presence of symptoms of depression was evaluated with self-administered Beck Depression Inventory (BDI). The influence of depression on autonomic nervous system was investigated measuring heart rate variability (HRV) and heart rate (HR) during 24-hour electrocardiographic monitoring. The end-points of the study were all-cause mortality, recurrent-AMI, revascularization and a composite end-point of all the previous. Potential confounders for depression status and events were entered into a multivariate regression model.

RESULTS

Fifteen patients met the criteria for MDD and 35 patients showed mild-to-moderate symptoms of depression; women had a higher prevalence of depression than men (35% vs 9%; p<0.01). Depression was not related to the severity of ischaemic disease or to other clinical and demographic variables. Patients with MDD showed lower HRV (76+/-25 SD vs 99+/-33 SD ms; p<0.01) and higher HR (77+/-12 SD vs 68+/-9 SD bpm; p<0.01) than patients without MDD; moreover mild to moderate symptoms of depression (BDI score > or = 10) were associated with lower HRV (84+/-25 SD vs 102+/-35 SD ms; p=0.01) but not with significantly higher HR. After a mean follow-up of 60 months MDD was associated with an increase of all-cause mortality (OR 12; 95% CI 2.6-56; p<0.01) and of composite end-point (OR 2; 95% CI 1.2-3.6; p=0.01) but not with re-AMI and revascularization. In a simple regression model HRV values were predictors of mortality (p<0.01). However when added in the multiple regression model HRV did not have an independent correlation with the end-points considered and did not modify the correlation between depression and mortality.

CONCLUSIONS

Patients with post-AMI depression have a cardiac autonomic dysfunction as reflected by decreased HRV and increased HR. This autonomic dysfunction seems not to be an independent mediator of the increased mortality observed in depressed patients during a 5-year follow-up.

Persistent depression affects adherence to secondary prevention behaviors after acute coronary syndromes

BACKGROUND

The persistence of depressive symptoms after hospitalization is a strong risk factor for mortality after acute coronary syndromes (ACS). Poor adherence to secondary prevention behaviors may be a mediator of the relationship between depression and increased mortality.

OBJECTIVE

To determine whether rates of adherence to risk reducing behaviors were affected by depressive status during hospitalization and 3 months later.

DESIGN

Prospective observational cohort study.

SETTING

Three university hospitals.

PARTICIPANTS

Five hundred and sixty patients were enrolled within 7 days after ACS. Of these, 492 (88%) patients completed 3-month follow-up.

MEASUREMENTS

We used the Beck Depression Inventory (BDI) to assess depressive symptoms in the hospital and 3 months after discharge. We assessed adherence to 5 risk-reducing behaviors by patient self-report at 3 months. We used chi2 analysis to compare differences in adherence among 3 groups: persistently nondepressed (BDI < 10 at hospitalization and 3 months); remittent depressed (BDI > or = 10 at hospitalization; < 10 at 3 months); and persistently depressed patients (BDI > or = 10 at hospitalization and 3 months).

RESULTS

Compared with persistently nondepressed, persistently depressed patients reported lower rates of adherence to quitting smoking (adjusted odds ratio [OR] 0.23, 95% confidence interval [95% CI] 0.05 to 0.97), taking medications (adjusted OR 0.50, 95% CI 0.27 to 0.95), exercising (adjusted OR 0.57, 95% CI 0.34 to 0.95), and attending cardiac rehabilitation (adjusted OR 0.5, 95% CI 0.27 to 0.91). There were no significant differences between remittent depressed and persistently nondepressed patients.

CONCLUSIONS

Persistently depressed patients were less likely to adhere to behaviors that reduce the risk of recurrent ACS. Differences in adherence to these behaviors may explain in part why depression predicts mortality after ACS.

Low rates of exercise in patients with metabolic syndrome after an acute coronary syndrome

BACKGROUND

Metabolic syndrome (MetSyn) has reached epidemic proportions; however, regular exercise can prevent its progression to type 2 diabetes.

HYPOTHESIS

The study was undertaken to determine both the rate and predictors of routine exercise 1 year after an acute coronary syndrome (ACS) in patients with MetSyn.

METHODS

In a registry of 1,199 patients presenting with ACS, those with MetSyn were identified using the modified NCEP-ATP III criteria. Baseline and 1-year exercise patterns were examined in these patients, and the characteristics of those who were exercising were then compared with those who were not. A multivariable logistic regression analysis was subsequently conducted to identify independent predictors of exercise at 1 year.

RESULTS

Of 273 patients with MetSyn, baseline and 1-year data about patients' exercise patterns were available for 170, of whom only 92 (54.2%) were exercising at 1 year. Characteristics that differed between those who were and those who were not exercising at 1 year included exercise at baseline (40 vs. 16.7%, p<0.001), Caucasian race (92.4 vs. 79.5%, p = 0.01), and body mass index (BMI) (30.4 +/- 4.3 vs. 32.1 +/- 5.0, p = 0.02). In a multivariable analysis, significant independent predictors of exercise were routine exercise at the time of admission for ACS (odds ratio [OR] = 2.6,95% confidence interval [CI] = 1.1-6.4), younger age (OR = 0.67 per 10-year increase [95% CI = 0.45-0.99]), and lower BMI (OR = 0.4 per 10-unit increase [95% CI = 0.17-0.911).

CONCLUSIONS

Almost half of patients with MetSyn did not participate in routine exercise 1 year after their admission for ACS. Innovative strategies are needed to increase exercise participation in such patients, particularly those not exercising at baseline as well as obese and older patients.

Cognitive performance following fluoxetine treatment in depressed patients post myocardial infarction

BACKGROUND

As depression is a considerable risk factor for an unfavourable course of myocardial infarction (MI), antidepressant treatment of post-MI depression and, inherent to MI status, polypharmacy has become an important issue.

OBJECTIVE

The present study is the first to evaluate cognitive side effects of fluoxetine, as part of a placebo-controlled double-blind trial, in patients with post-first MI depression.

METHODS

Cognitive performance of 54 depressed patients post first-MI, treated with fluoxetine or placebo was compared. Cognitive performance was tested before and after 9 weeks of treatment using the Visual Verbal Learning Test, Concept Shifting Task, Stroop Colour-Word Test and Letter-Digit-Substitution Test.

RESULTS

The median number of cardiovascular drugs taken by MI patients was 4.9. There were no differences between the fluoxetine and the placebo group on cognitive performance.

CONCLUSION

In sum, there were no negative side effects of fluoxetine compared with placebo on cognition in depressed MI patients, simultaneously treated with cardiac drugs.

Psychosocial predictors of cardiac rehabilitation quality-of-life outcomes

OBJECTIVE

This study investigated hostility, social support, coping, depression, and their contributions to concurrent and posttreatment quality of life (QoL) among a group of patients participating in a 6-week cardiac rehabilitation program.

METHOD

Both direct and mediational relationships among psychosocial factors, QoL baseline, and QoL outcome were examined using structural equation modeling analysis, while age, education, and severity of illness (risk for future event) were controlled.

RESULTS

The final model was well supported (chi(2)=64.88, df=56, P>.05; CFI=.99, RMSEA=.04). Results indicated that baseline QoL, hostility, and depressive symptom severity directly and independently predicted QoL outcome, while depression and hostility were also associated with baseline QoL. Hostility, social support, and maladaptive coping also contributed to baseline and follow-up QoL by their associations with depression.

CONCLUSION

Psychosocial characteristics were interrelated, and they predicted postrehabilitation QoL outcome directly or indirectly through depression symptom severity.

Pre-Coronary Artery Bypass Graft Measures and Enrollment in Cardiac Rehabilitation

PURPOSE

The aim of this study was to examine the relationship between exercise tolerance, functional status, exercise behavior, and enrollment in cardiac rehabilitation (CR), preoperatively in individuals undergoing coronary artery bypass graft (CABG) surgery.

METHODS

Seventy-eight individuals undergoing CABG were evaluated 1 to 7 days preoperatively using the following measures: 2-minute walk test (2MWT), Duke Activity Status Index (DASI), Cardiac Exercise Self-Efficacy Instrument (CESEI), Stages of Change Questionnaire (SCQ), Short-Form 12 (SF-12), Hospital Anxiety Depression scale, location of residence, and education level. Participants were contacted via telephone 10 to 12 weeks postoperatively to determine if they were referred and enrolled in CR. Participants completed mailed questionnaires for follow-up. In subsequent telephone interviews, individuals who were not enrolled in CR were asked to provide reasons for nonenrollment.

RESULTS

Overall enrollment in CR was 46%. No significant differences were found in 2MWT, CESEI, and DASI scores between enrolled and nonenrolled participants. Fifty-seven percent of urban-dwelling participants enrolled in CR compared to 29% of rural-dwelling participants (P < .01). Similarly, 65% of individuals with post-secondary education enrolled in CR compared to 38% of individuals without a post-secondary education (P = .05). The primary reasons for nonenrollment were behavioral intentions toward exercise and CR, accessibility, and healthcare team recommendation. Individuals who enrolled in CR demonstrated a larger postoperative improvement in CESEI score.

CONCLUSIONS

Location of residence and education level predicted CR enrollment, whereas preoperative exercise tolerance, functional status, and exercise attitudes did not predict enrollment.

Social inequality in patients??? physical and psychological state and participation in rehabilitation after myocardial infarction in Germany

Several Anglo-American studies found that vertical social characteristics made a difference in the utilization of cardiac rehabilitation programmes. A social gradient was also demonstrated for prevalence of risk factors, psychological strain and psychosocial resources. This study investigated social differences for these factors in a group of 536 patients who had suffered from a myocardial infarction. In contrast to findings in other industrialized countries, German patients of higher status groups made less use of cardiac rehabilitative services than patients with a lower and middle class status. However, similar to Anglo-American findings, patients with a lower socio-economic status were more likely to be smokers and more likely to be obese than other patients. Also they had higher levels of comorbidity and depression and lower self-efficacy expectations. Thus while there were no social disadvantages in terms of participation in cardiac rehabilitation programmes, which seems to be largely due to the specific characteristics of the German health care system, patients of lower socio-economic status seem to have worse baseline conditions and as a result of this a specific need for rehabilitative support.

Factors affecting the uptake of cardiac rehabilitation services in a rural locality

INTRODUCTION

A number of studies have investigated factors affecting uptake of cardiac rehabilitation services. However, little information on factors affecting uptake of services in rural localities is available.

STUDY DESIGN

A cross-sectional survey.

METHODS

A survey of patients eligible for cardiac rehabilitation was undertaken to investigate uptake of services. The effects of individual and geographic factors on service utilization were explored.

RESULTS

Utilization rates for cardiac rehabilitation services within the South Staffordshire locality are low, with 59.3% of eligible patients invited to attend cardiac rehabilitation services following discharge from hospital, 38.6% attending and 22.5% completing the programme. Two factors were independently associated with low service utilization. Patients under the age of 65 years are 1.90 [95% confidence intervals (CI) 1.01-3.65] times more likely to complete rehabilitation than patients aged over 65 years, and women are only 0.48 (95% CI 0.22-1.03) times as likely as men to complete rehabilitation. The major reported barrier to utilization of services was access. This included problems with public transport, parking and the time and location of classes. Access and medical problems were significantly higher in older people and may have contributed to their low overall completion rate. Electoral ward deprivation, geographical access score, living in an urban or rural electoral ward, electoral ward of residence and provider were not significantly associated with service utilization.

CONCLUSIONS

Overall, utilization rates were low. No geographical factors were associated with uptake of services, although the possible effect may have been mediated by the relative affluence of the locality. Two individual factors, age and sex, were most likely to influence uptake.

Prediction of depressive disorder following myocardial infarction data from the Myocardial INfarction and Depression-Intervention Trial (MIND-IT)

BACKGROUND

Depression following myocardial infarction (MI) is associated with complicated cardiac rehabilitation, non-compliance and poor prognosis. Whether depression following MI can be predicted from variables routinely assessed during hospitalization for MI is unknown.

METHODS

Using data from the Myocardial INfarction and Depression-Intervention Trial (MIND-IT), we identified 2,177 MI patients (mean age 63 years; 23% female). Patients were randomly divided into a derivation and a validation sample. In the derivation sample, we analyzed variables potentially associated with the development of post-MI depressive disorder, which were tested in the validation sample.

RESULTS

In the year following MI, 18.5% suffered from depressive disorder (ICD-10 criteria). In a multivariate model, factors associated with depression were younger age (OR 1.94; CI 1.38-2.74), hypercholesterolemia (OR 1.68; CI 1.08-2.61), the use of calcium channel blockers at discharge (OR 1.80; CI 1.20-2.71), and left ventricular ejection fraction (LVEF) (OR 4.14 for patients with LVEF <30%; CI (2.42-7.10). The derived predictors were tested in the validation sample. The final model yielded two clinical predictors, i.e., younger age and severe LV-dysfunction, which correctly predicted post-discharge depression status in 82.9% of the MI patients. The model yielded a high negative predictive value (89%). A positive depression questionnaire (BDI) during hospitalization increased the positive predictive value of 23% to 52%.

CONCLUSIONS

During hospitalization for MI and using a two-step strategy with common clinical variables, i.e., younger age, severe LV-dysfunction and BDI score during hospitalization, it is possible to identify MI patients with a high risk for subsequent development of depression.

Psychological effects of a short behavior modification program in patients with acute myocardial infarction or coronary artery bypass grafting. A randomized controlled trial

OBJECTIVE

The effects of a short intervention on behavioral risk factor modification in patients with coronary artery disease (CAD) on Type A behavior, vital exhaustion, and depression were studied in a randomized controlled trial.

METHODS

Acute myocardial infarction patients or patients who underwent coronary artery bypass grafting (CABG) were randomly assigned to an 8-week multiple risk modification group program (n = 94) or to a control group (n = 90) that received usual care with standard physical exercise training. Patients were assessed before intervention, directly after intervention, and at 9-month follow-up.

RESULTS

The intervention was effective in reducing hostility and total Type A behavior at postintervention (P = .01) and at 9-month follow-up (P = .03). The intervention had no overall impact on vital exhaustion and depression, measured by the Beck Depression Inventory (BDI), whereas we unexpectedly found that the percentage of patients with major depression was reduced in the control group but not in the intervention group.

CONCLUSION

The results indicate that a short behavioral intervention for coronary patients can result in relatively large and persistent reductions in cognitive aspects of Type A behavior and hostility, in particular. In view of the unwanted findings on the diagnosis of depression, however, we do not unequivocally advise the intervention to the general population of AMI and CABG patients.

Can doctors and nurses recognize depression in patients hospitalized with an acute myocardial infarction in the absence of formal screening?

OBJECTIVE

The objective of this study was to determine the ability of cardiovascular healthcare workers to assess the presence or absence of symptoms of depression in patients hospitalized with acute myocardial infarction (AMI) in the absence of formal screening.

METHODS

Patients admitted with AMI underwent screening using the Beck Depression Inventory (BDI) administered by a research assistant. The cardiovascular nurse, medicine resident or intern, and attending cardiologist caring for the patient were then approached (blinded to the BDI results) and asked to assess, using a visual analog scale, whether the patient had symptoms that would warrant further evaluation for depression.

RESULTS

BDI screening and at least one provider assessment were completed for 60 patients with AMI. A total of 18 of 60 patients (30.0%) had a BDI score of > or =10. Symptoms of depression were considered not present in 24 of 32 patient assessments when the BDI was > or =10 (75% false-negatives). The mean BDI score of patients assessed as depressed by at least one provider (6.7 +/- 6.3) was no different from the mean BDI score of patients assessed as not depressed (7.5 +/- 7.2, p = .67). Overall, there was little correlation between BDI scores and provider assessments, and this was not influenced by provider type or provider gender.

CONCLUSIONS

Cardiovascular nurses and medicine residents and interns underrecognize depression in patients with AMI in the absence of formal screening. Formal screening for symptoms of depression should be considered part of routine AMI care.

Prevalence of Depressive Disorders in Men and Women Enrolled in Cardiac Rehabilitation

PURPOSE

Epidemiological studies have demonstrated that depression is an independent risk factor for the development and recurrence of coronary heart disease (CHD). The prevalence of depressive disorders, however, is not well documented in CHD patients enrolled in cardiac rehabilitation (CR). The purpose of this study was to estimate the prevalence of current and lifetime depressive disorders in the CR setting.

METHODS

One hundred ten men and women diagnosed with CHD and enrolled in a phase II CR program were screened via a psychiatric, structured interview to assess current and lifetime history of major depressive disorder, minor depression, and dysthymic disorder.

RESULTS

A total of 17 (15.5%) individuals screened positive for a current depressive disorder at entry into the CR program, with 10 (9.1%) individuals screening positive for major depressive disorder, 7 (6.4%) for minor depression, and 6 (5.5%) for dysthymic disorder. With respect to lifetime prevalence of mood disorders, 29 (26.4%) individuals met the diagnostic criteria for at least one depressive disorder during their lifetime. The lifetime prevalence of major depressive disorder, minor depression, and dysthymic disorder was 11.8%, 14.5%, and 10.9%, respectively. Female CR participants evidence significantly higher current and lifetime prevalence rates for depressive disorders compared to their male counterparts.

CONCLUSIONS

The results of this study suggest that a substantial number of CHD patients enrolled in CR report a clinically significant history of depression. Efforts to assess and treat depression are needed in the CR setting and may be associated with better adherence to lifestyle modification programs.