The prevalence and impact of depression and anxiety in cardiac rehabilitation: A longitudinal cohort study

Psychological stress in heart failure: a potentially actionable disease modifier

Psychological stress is common in patients with heart failure, due in part to the complexities of effective disease self-management and progressively worsening functional limitations, including frequent symptom exacerbations and hospitalizations. Emerging evidence suggests that heart failure patients who experience higher levels of stress may have a more burdensome disease course, with diminished quality of life and increased risk for adverse events, and that multiple behavioral and pathophysiological pathways are involved. Furthermore, the reduced quality of life associated with heart failure can serve as a life stressor for many patients. The purpose of this review is to summarize the current state of the science concerning psychological stress in patients with heart failure and to discuss potential pathways responsible for the observed effects. Key knowledge gaps are also outlined, including the need to understand patterns of exposure to various heart failure-related and daily life stressors and their associated effects on heart failure symptoms and pathophysiology, to identify patient subgroups at increased risk for stress exposure and disease-related consequences, and the effect of stress specifically for patients who have heart failure with preserved ejection fraction. Stress is a potentially modifiable factor, and addressing these gaps and advancing the science of stress in heart failure is likely to yield important insights about actionable pathways for improving patient quality of life and outcomes.

A Behavioral Change Smartphone App and Program (ToDo-CR) to Decrease Sedentary Behavior in Cardiac Rehabilitation Participants: Prospective Feasibility Cohort Study

BACKGROUND

Cardiac rehabilitation participants are encouraged to meet physical activity guidelines to reduce the risk of repeat cardiac events. However, previous studies have found that physical activity levels are low and sedentary behavior is high, both during and after cardiac rehabilitation. There is potential for smartphone apps to be effective in reducing sedentary behavior, although among the few studies that have investigated smartphone apps in cardiac rehabilitation, none targeted sedentary behavior.

OBJECTIVE

This study aims to evaluate the feasibility of a behavioral smartphone app (Vire) and a web-based behavior change program (ToDo-CR) to decrease sedentary behavior in cardiac rehabilitation participants.

METHODS

Using a single-center, pre-post design, participants were recruited by nursing staff on admission to cardiac rehabilitation. All eligible participants installed the Vire app, were given a Fitbit Flex, and received the 6-week ToDo-CR program while attending cardiac rehabilitation. The ToDo-CR program uses personalized analytics to interpret important behavioral aspects (physical activity, variety, and social opportunity) and real-time information for generating and suggesting context-specific actionable microbehavioral alternatives (Do's). Do's were delivered via the app, with participants receiving 14 to 19 Do's during the 6-week intervention period. Outcome measures were collected at 0, 6, and 16 weeks. The assessors were not blinded. Feasibility outcomes included recruitment and follow-up rates, resource requirements, app usability (Unified Theory of Acceptance and Use of Technology 2 [UTAUT2] questionnaire), and objectively measured daily minutes of sedentary behavior (ActiGraph) for sample size estimation. Secondary outcomes included functional aerobic capacity (6-min walk test), quality of life (MacNew Heart Disease Health-Related Quality of Life Questionnaire), anxiety and depression (Hospital Anxiety and Depression Scale questionnaire), BMI, waist circumference, waist-to-hip ratio, and blood pressure.

RESULTS

Between January and May 2019, 20 participants were recruited consecutively. One-third of people who commenced cardiac rehabilitation were eligible to participate. Other than declining to take part in the study (15/40, 38%), not having a smartphone was a major reason for exclusion (11/40, 28%). Those excluded without a smartphone were significantly older than participants with a smartphone (mean difference 20 [SD 5] years; P<.001). Participants were, on average, aged 54 (SD 13) years, mostly male (17/20, 85%), and working (12/20, 67%). At 6 weeks, 95% (19/20) of participants were assessed, and 60% (12/20) of participants were assessed at 16 weeks. Participants were relatively satisfied with the usability of the app (UTAUT2 questionnaire). Overall, participants spent 11 to 12 hours per day sitting. There was a medium effect size (Cohen d=0.54) for the reduction in sedentary behavior (minutes per day) over 16 weeks.

CONCLUSIONS

The use of a behavioral smartphone app to decrease sitting time appears to be feasible in cardiac rehabilitation. A larger randomized controlled trial is warranted to determine the effectiveness of the app.

Shorter Wait Times to Cardiac Rehabilitation Associated With Greater Exercise Capacity Improvements: A MULTISITE STUDY

PURPOSE

Comprehensive exercise-based cardiac rehabilitation (CR) results in improved, though highly variable, exercise capacity outcomes. Whether modifiable factors such as CR program wait time and session duration are associated with exercise capacity outcomes has not been adequately investigated.

METHODS

Patients with coronary heart disease (±primary and elective percutaneous coronary interventions, cardiac surgery) who participated in CR programs involved in a three-state audit (n = 32 sites) were eligible. Exercise capacity was measured using the 6-min walk test before and after a 6- to 12-wk supervised exercise program. CR program characteristics were also recorded (wait time, number of sessions). Correlations and linear mixed-effects models were used to identify associations between sociodemographic and CR program characteristics and change in exercise capacity.

RESULTS

Patients (n = 894) had a mean age of 65.9 ± 11.8 yr, 71% were males, 33% were referred for cardiac surgery, and median wait time was 16 d (interquartile range 9, 26). Exercise capacity improved significantly and clinically (mean increase 70.4 ± 61.8 m). After adjusting for statistically significant factors including younger age (<50 vs ≥80 yr [β = 52.07]), female sex (β = -15.86), exercise capacity at CR entry (β = 0.22) and those nonsignificant (ethnicity, risk factors, and number of sessions), shorter wait time was associated with greater exercise capacity improvement (β = 0.23).

CONCLUSIONS

This study confirms that greater exercise capacity improvements occur with shorter wait times. Coordinators should prioritize implementing strategies to shorten wait time to optimize the benefits of CR.

Current challenges in cardiac rehabilitation: strategies to overcome social factors and attendance barriers

INTRODUCTION

Cardiac rehabilitation (CR) significantly reduces secondary cardiovascular events and mortality and is a class 1A recommendation by the American Heart Association (AHA) and American College of Cardiology (ACC). However, it remains an underutilized intervention and many eligible patients fail to enroll or complete CR programs. The aim of this review is to identify barriers to CR attendance and discuss strategies to overcome them.

AREAS COVERED

Specific barriers to CR attendance and participation will be reviewed. This will be followed by a discussion of solutions/strategies to help overcome these barriers with a particular focus on home-based CR (HBCR).

EXPERT OPINION

HBCR alone or in combination with center-based CR (CBCR) can help overcome many barriers to traditional CBCR participation, such as schedule flexibility, time commitment, travel distance, cost, and patient preference. Using remote coaching with indirect exercise supervision, HBCR has been shown to have comparable benefits to CBCR. At this time, however, funding remains the main barrier to universal incorporation of HBCR into health systems, necessitating the need for additional cost benefit analysis and outcome studies. Ultimately, the choice for HBCR should be based on patient preference and availability of resources.

Predictors of posttraumatic stress symptoms and perceived health after an acute coronary syndrome: the role of experiential avoidance, anxiety sensitivity, and depressive symptoms

Objectives: The identification of psychological markers of the posttraumatic stress reaction after a cardiac event is relevant in the management of cardiovascular risk factors. The aim of the study to test the contribution of experiential avoidance, anxiety sensitivity, and depressive symptoms to acute coronary syndrome posttraumatic stress symptoms and perceived health (both measured 6 months later), and to determine whether the associations between experiential avoidance, anxiety sensitivity, and depressive symptoms with perceived health were mediated by the posttraumatic stress symptoms.Design: 180 patients with acute coronary syndrome completed a survey over a 6-month period.Results: Anxiety sensitivity and depressive symptoms but not experiential avoidance contributed significantly to posttraumatic stress symptoms. Depressive symptoms and posttraumatic symptoms but neither anxiety sensitivity nor experiential avoidance had a significant association on perceived health. Acute coronary syndrome posttraumatic symptoms significantly mediated the association of depressive symptoms with perceived health. That is, increased depressive symptoms was significantly associated with higher levels of posttraumatic symptoms, which in turn predicted lower levels of perceived health.Conclusions: Understanding the psychological factors that are associated with post-acute coronary syndrome posttraumatic stress symptoms may help to identify patients at risk in order to refer them to the appropriate psychological care service.

The association between heart diseases and suicide: a nationwide cohort study

OBJECTIVE

To assess the association between specific heart diseases and suicide.

DESIGN

Nationwide retrospective cohort study.

PARTICIPANTS

A total of 7 298 002 individuals (3 640 632 males and 3 657 370 females) aged ≥15 years and living in Denmark during 1980-2016.

MAIN OUTCOME MEASURES

Incidence rate ratios (IRR) with 95% confidence intervals. In multivariate analysis, we adjust for sex, period, age group, living status, income level, Charlson Comorbidity Index, psychiatric disorders prior to heart disease and self-harm prior to heart disease.

RESULTS

Excess suicide rate ratios were found for following disorders: heart failure (IRR: 1.48; 95% CI: 1.38-1.58); cardiomyopathy (IRR: 1.41; 95% CI: 1.16-1.70); acute myocardial infarction (IRR: 1.28; 95% CI: 1.21-1.36); cardiac arrest with successful resuscitation (IRR: 4.75; 95% CI: 3.57-6.33); atrial fibrillation and flutter (IRR: 1.42; 95% CI: 1.32-1.52); angina pectoris (IRR: 1.19; 95% CI: 1.12-1.26); and ventricular tachycardia (IRR: 1.53; 95% CI: 1.20-1.94). A higher rate of suicide was noted during the first 6 months after the diagnosis of heart failure (IRR: 2.38; 95% CI: 2.04-2.79); acute myocardial infarction (IRR: 2.24; 95% CI: 1.89-2.66); atrial fibrillation and flutter (IRR: 2.70; 95% CI: 2.30-3.18); and angina pectoris (IRR: 1.83; 95% CI: 1.53-2.19) when compared to later.

CONCLUSION

Several specific disorders were found to be associated with elevated rates of suicide. Additionally, we found temporal associations with higher suicide rates in the first time after diagnosis. Our results underscore the importance of being attentive towards psychological distress in individuals with heart disease.