Psychic effects of physical training and relaxation therapy after myocardial infarction

Psychologically-enhanced cardiac rehabilitation for psychological and functional improvement in patients with cardiovascular disease: a systematic review with meta-analysis and future research directions

OBJECTIVE

To systematically review the effectiveness of psychologically-enhanced cardiac rehabilitation (CR) in improving psychological and functional outcomes in patients with cardiovascular disease.

DATA SOURCES

A systematic search was performed in PubMed, Scopus, Cochrane Library, Embase, and Web of Science, up to January 31, 2024.

STUDY SELECTION

Two reviewers independently identified randomized clinical trials that evaluated the effectiveness of psychologically-enhanced CR in improving psychological and functional outcomes in patients with cardiovascular disease. The search yielded 1848 results. Finally, data from 14 studies (1531 participants) were included in the review.

DATA EXTRACTION AND DATA SYNTHESIS

Information regarding cardiac rehabilitation phase, duration of the intervention, group characteristics, measured outcomes, and the conclusions drawn by the authors was extracted. The Revised Cochrane risk-of-bias tool for Randomized Trials was used to evaluate the methodological quality.

RESULTS

Pooled results indicate that psychologically-enhanced CR is more effective than specific cardiac training alone in maintaining lower resting blood pressure, with a mean difference of -3.09 (95% CI: -5.18 to -1.00). Furthermore, psychologically-enhanced CR shows superiority in improving patients' quality of life compared to specific cardiac training alone, with a standardized mean difference of 0.15 (95% CI: 0.01 to 0.31). Analyses of depression and anxiety level, exercise tolerance, and blood lipid profile did not show significant differences between the two treatment conditions.

CONCLUSION

Psychologically-enhanced CR shows a positive effect on reducing resting blood pressure and improving the quality of life. However, the supportive methods were of limited effectiveness in addressing the psychological aspects of health.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022304063. CONTRIBUTION OF THE PAPER.

Respiratory therapy for the treatment of anxiety: Meta-analytic review and regression

OBJECTIVE

Respiratory abnormalities are a hallmark of anxiety symptomatology and may serve as clinically useful modifiers for alleviating anxiety symptoms. However, gold-standard anxiety treatments (e.g., cognitive-behavioral interventions) often do not directly address respiratory components despite their theoretical utility and clinical accessibility. This review examined the clinical effectiveness of respiratory interventions, interventions that directly target respiration abnormalities and processes, in treating trait anxiety symptoms.

METHODS

The final analysis included 40 randomized controlled trials including at least one measure of trait anxiety, a respiratory-focused intervention group, and a non-respiratory control-group (active or inactive treatment). Overall effects of respiratory focused interventions were examined, as well as the effect of hypothesized moderators.

RESULTS

Respiratory component interventions yielded significantly greater improvements (moderate to large effect) in anxiety symptoms than controls, with the stronger effects observed in comparison to inactive, rather than active, control conditions. Significant heterogeneity in findings suggests that variability in intervention design, population, and control comparison may obfuscate interpretation of findings.

CONCLUSIONS

Evidence supports the clinical utility of respiratory interventions as either an independent anxiety treatment, or as an adjunct to other interventions. Clinical and research implications of findings along with recommendations for ongoing investigations in this domain are discussed.

Treatment of Anxiety in Patients With Coronary Heart Disease: A Systematic Review

BACKGROUND

Anxiety is common in patients with coronary heart disease (CHD) and is associated with an increased risk for adverse outcomes. There has been a relative paucity of studies concerning treatment of anxiety in patients with CHD.

OBJECTIVE

We conducted a systematic review to organize and assess research into the treatment of anxiety in patients with CHD.

METHODS

We searched CCTR/CENTRAL, MEDLINE, EMBASE, PsycINFO, and CINAHL for randomized clinical trials conducted before October 2016 that measured anxiety before and after an intervention for patients with CHD.

RESULTS

A total of 475 articles were subjected to full text review, yielding 112 publications that met inclusion criteria plus an additional 7 studies from reference lists and published reviews, yielding 119 studies. Sample size, country of origin, study quality, and demographics varied widely among studies. Most studies were conducted with nonanxious patients. The Hospital Anxiety and Depression Scale and State-Trait Anxiety Inventory were the most frequently used instruments to assess anxiety. Interventions included pharmacological, counseling, relaxation-based, educational, or "alternative" therapies. Forty (33% of total) studies reported that the interventions reduced anxiety; treatment efficacy varied by study and type of intervention. Elevated anxiety was an inclusion criterion in only 4 studies, with inconsistent results.

CONCLUSION

Although there have been a number of randomized clinical trials of patients with CHD that assessed anxiety, in most cases anxiety was a secondary outcome, and only one-third found that symptoms of anxiety were reduced with treatment. Future studies need to target anxious patients and evaluate the effects of treatment on anxiety and relevant clinical endpoints.

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

Psychological interventions for coronary heart disease

BACKGROUND

Psychological symptoms are strongly associated with coronary heart disease (CHD), and many psychological treatments are offered following cardiac events or procedures.

OBJECTIVES

Update the existing Cochrane review to (1) determine the independent effects of psychological interventions in patients with CHD (principal outcome measures included total or cardiac-related mortality, cardiac morbidity, depression, and anxiety) and (2) explore study-level predictors of the impact of these interventions.

SEARCH STRATEGY

The original review searched Cochrane Controleed Trials Register (CCTR, Issue 4, 2001), MEDLINE, EMBASE, PsycINFO, and CINAHL to December 2001. This was updated by searching the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE, PsycINFO and CINAHL from 2001 to January 2009. In addition, we searched reference lists of papers, and expert advice was sought for the original and update review.

SELECTION CRITERIA

Randomised controlled trials of psychological interventions compared to usual care, administered by trained staff. Only studies estimating the independent effect of the psychological component with a minimum follow-up of six months. Adults with specific diagnosis of CHD.

DATA COLLECTION AND ANALYSIS

Titles and abstracts of all references screened for eligibility by two reviewers independently; data extracted by the lead author and checked by a second reviewer. Authors contacted where possible to obtain missing information.

MAIN RESULTS

There was no strong evidence that psychological intervention reduced total deaths, risk of revascularisation, or non-fatal infarction. Amongst a smaller group of studies reporting cardiac mortality there was a modest positive effect of psychological intervention (relative risk: 0.80 (95% CI 0.64 to 1.00)). Furthermore, psychological intervention did result in small/moderate improvements in depression, standardised mean difference (SMD): -0.21 (95% CI -0.35, -0.08) and anxiety, SMD: -0.25 (95% CI -0.48 to -0.03). Results for mortality indicated some evidence of small-study bias, though results for other outcomes did not. Meta regression analyses revealed four significant predictors of intervention effects on depression were found: (1) an aim to treat type-A behaviours (ß = -0.32, p = 0.03) were more effective than other interventions. In contrast, interventions which (2) aimed to educate patients about cardiac risk factors (ß = 0.23, p = 0.03), (3) included client-led discussion and emotional support as core therapeutic components (ß = 0.31, p < 0.01), or (4) included family members in the treatment process (ß = 0.26, p < 0.01) were significantly less effective.

AUTHORS' CONCLUSIONS

Psychological treatments appear effective in treating psychological symptoms of CHD patients. Uncertainly remains regarding the subgroups of patients who would benefit most from treatment and the characteristics of successful interventions.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Exercise and relaxation intervention for breast cancer survivors: feasibility, acceptability and effects

OBJECTIVE

Although evidence mounts regarding the beneficial effects of physical activity (PA) interventions for breast cancer survivors, not all interventions have produced significant improvement in mood. Relaxation training may be a promising strategy for enhancing mood effects from these interventions. The goals of Be Calm and Move On were to assess the feasibility, acceptability and preliminary effects of a 12-week combined PA and relaxation intervention for breast cancer survivors.

METHODS

Twenty-three early-stage breast cancer survivors were enrolled and 19 were retained for the intervention and 12- and 24-week follow-ups. Participants received a theoretically grounded intervention delivered via telephone.

RESULTS

Participant evaluations of the intervention indicated that it was feasible and acceptable (e.g. 100% would recommend it to others); objective data further supported its feasibility (e.g. 83% completed the trial, 91% of intervention calls were received). In addition, when comparing 12- and 24-week follow-up data to baseline data, participants demonstrated significantly increased PA, improved mood and sleep quality, and reduced fatigue (p's<0.05).

CONCLUSION

Thus, this pilot study suggests that the intervention is feasible and acceptable and produces promising effects on mood, sleep, and fatigue.

The effect of biofeedback on function in patients with heart failure

Decreased HRV has been consistently associated with increased cardiac mortality and morbidity in HF patients. The aim of this study is to determine if a 6-week course of heart rate variability (HRV) biofeedback and breathing retraining could increase exercise tolerance, HRV, and quality of life in patients with New York Heart Association Class I-III heart failure (HF). Participants (N = 29) were randomly assigned to either the treatment group consisting of six sessions of breathing retraining, HRV biofeedback and daily practice, or the comparison group consisting of six sessions of quasi-false alpha-theta biofeedback and daily practice. Exercise tolerance, measured by the 6-min walk test (6MWT), HRV, measured by the standard deviation of normal of normal beats (SDNN), and quality of life, measured by the Minnesota Living with Congestive Heart Failure Questionnaire, were measured baseline (week 0), post (week 6), and follow-up (week 18). Cardiorespiratory biofeedback significantly increased exercise tolerance (p = .05) for the treatment group in the high (>or=31%) left ventricular ejection fraction (LVEF) category between baseline and follow-up. Neither a significant difference in SDNN (p = .09) nor quality of life (p = .08), was found between baseline and follow-up. A combination of HRV biofeedback and breathing retraining may improve exercise tolerance in patients with HF with an LVEF of 31% or higher. Because exercise tolerance is considered a strong prognostic indicator, cardiorespiratory biofeedback has the potential to improve cardiac mortality and morbidity in HF patients.

A bio-psycho-socio-molecular approach to pain and stress management

Stress and trauma are interconnected with the experience of pain. This connection is due to a physiological coupling of underlying molecular autoregulatory mechanisms, as well as phenomenological similarities. Nonpharmaceutical therapeutic approaches such as the relaxation response, a process that supports physiological stress reduction and decreases the negative mental and physical effects of stress, also facilitate pain relief, again demonstrating physiological commonalities. These behavioral approaches have a critical impact on molecular patterns of autoregulation, leading to the assumption of a bio-psycho-socio-molecular model of autoregulation, including stress and pain. Thus, molecules and behavior may be seen as two sides of the same problem in pain and stress relief.

[Usefulness of relaxation techniques for patients with ischaemic cardiopathy: intervention in a health district]

OBJECTIVE

To determine the effectiveness of a programme of relaxation used in primary care for patients with ischaemic cardiopathy (IC) through evaluation of the anxiety levels and the quality of life of these patients.

DESIGN

Controlled intervention study without randomisation.

SETTING

Two primary care teams in the city of Sabadell.

PARTICIPANTS

Patients from 15 to 69 years old with IC: intervention group (IG), 57 patients; control group (CG), 47. Interventions. In the IG, conventional treatment and relaxation techniques (RT). In the CG, conventional treatment.

MAIN MEASUREMENTS

Degree of anxiety was measured by means of the STAI scale-questionnaire. Quality of life was measured by means of the SF-36 health questionnaire. Blood pressure and smoking were recorded.

RESULTS

At 12 months, 70% of patients practised relaxation at least for a short time. In the IG, anxiety dropped significantly at 3, 6, and 12 months, especially the anxiety characteristics scale, which was still significant at 12 months (P=.002). Quality of life at 3 and 6 months in the IG showed better scores in most dimensions except body pain. At 12 months, scores continued to be better than at the start (social function P=.012), except in the mental health dimension. No significant changes were found in blood pressure or tobacco consumption.

CONCLUSIONS

Our results suggest that an RT workshop in primary care is beneficial if correctly applied and leads to improved quality of life.

Psychological interventions for coronary heart disease

BACKGROUND

Psychological interventions can form part of comprehensive cardiac rehabilitation programmes (CCR). These interventions may include stress management interventions, which aim to reduce stress, either as an end in itself or to reduce risk for further cardiac events in patients with heart disease.

OBJECTIVES

To determine the effectiveness of psychological interventions, in particular stress management interventions, on mortality and morbidity, psychological measures, quality of life, and modifiable cardiac risk factors, in patients with coronary heart disease (CHD).

SEARCH STRATEGY

We searched CCTR to December 2001 (Issue 4, 2001), MEDLINE 1999 to December 2001 and EMBASE 1998 to the end of 2001, PsychINFO and CINAHL to December 2001. In addition, searches of reference lists of papers were made and expert advice was sought.

SELECTION CRITERIA

RCTs of non-pharmacological psychological interventions, administered by trained staff, either single modality interventions or a part of CCR with minimum follow up of 6 months. Adults of all ages with CHD (prior myocardial infarction, coronary artery bypass graft or percutaneous transluminal coronary angioplasty, angina pectoris or coronary artery disease defined by angiography). Stress management (SM) trials were identified and reported in combination with other psychological interventions and separately.

DATA COLLECTION AND ANALYSIS

Studies were selected, and data were abstracted, independently by two reviewers. Authors were contacted where possible to obtain missing information.

MAIN RESULTS

Thirty six trials with 12,841 patients were included. Of these, 18 (5242 patients) were SM trials. Quality of many trials was poor with the majority not reporting adequate concealment of allocation, and only 6 blinded outcome assessors. Combining the results of all trials showed no strong evidence of effect on total or cardiac mortality, or revascularisation. There was a reduction in the number of non-fatal reinfarctions in the intervention group (OR 0.78 (0.67, 0.90), but the two largest trials (with 4809 patients randomized) were null for this outcome, and there was statistical evidence of publication bias. Similar results were seen for the SM subgroup of trials. Provision of any psychological intervention or SM intervention caused small reductions in anxiety and depression. Few trials reported modifiable cardiac risk factors or quality of life.

REVIEWERS' CONCLUSIONS

Overall psychological interventions showed no evidence of effect on total or cardiac mortality, but did show small reductions in anxiety and depression in patients with CHD. Similar results were seen for SM interventions when considered separately. However, the poor quality of trials, considerable heterogeneity observed between trials and evidence of significant publication bias make the pooled finding of a reduction in non-fatal myocardial infarction insecure.

Comorbidity of depression with other medical diseases in the elderly

A major factor in the context of evaluating depression in the elderly is the role of medical problems. With aging there is a rapid increase in the prevalence of a number of medical disorders, including cancer, heart disease, Parkinson's disease, Alzheimer's disease, stroke, and arthritis. In this article, we hope to bring clarity to the definition of comorbidity and then discuss a number of medical disorders as they relate to depression. We evaluate medical comorbidity as a risk factor for depression as well as the converse, that is, depression as a risk factor for medical illness. Most of the disorders that we focus on occur in the elderly, with the exception of HIV infection. This review focuses exclusively on unipolar disorder. The review summarizes the current state of the art and also makes recommendations for future directions.

Progressive muscle relaxation in cardiac rehabilitation: a pilot study

Learning to manage stress is an important lifestyle change for participants in cardiac rehabilitation programs. Progressive muscle relaxation (PMR) is one stress management approach that has produced positive benefits among different patient populations. The purpose of this study was to identify the effects of learning and practicing PMR in a population of cardiac rehabilitation patients. Blood pressure and heart rate data, and scores on the Spielberger State-Trait Anxiety Inventory (STAI) were collected from a treatment group and a control group of patients enrolled in phases II and III of cardiac rehabilitation. Analysis of the data revealed positive effects of PMR on the variables heart rate and state of anxiety. In addition, written evaluations of PMR from patients in the treatment group indicated a high degree of subjective satisfaction with PMR as a means to reduce stress in their lives.

Return to work after myocardial infarction/coronary artery bypass grafting: patients' and physicians' initial viewpoints and outcome 12 months later

Nonmedical factors play an important role in determining whether patients resume their work after myocardial infarction or CABG. The main questions dealt with in this study are: What is the respective basis of physicians' and patients' judgements as far as vocational disabilities are concerned, and what are the decisive factors that facilitate a prediction as to who will return to work and who will not? 132 male patients participating in a cardiac rehabilitation program served as subjects. The age group was limited to patients between 40 and 59 yr of age. The work situation 12 months following rehabilitation is known for 119 subjects; 74 had resumed their occupations. Results of regression analyses show that patients' and physicians' views on disabilities and re-employment are based on different factors. The physicians derive their estimates mainly from medical variables (cardiac status and comorbidity), whereas the patients' views are based on the overall health status, their former job status, job satisfaction, and negative incentives for the return to work. Three variables were found that allow a prediction to be made as to re-employment in 85% of all cases: (1) age, (2) patients' feelings about the extent to which they are disabled by their cardiac problem, and (3) the physicians' views on the extent to which the patient is vocationally disabled by his overall medical situation. Medical variables (e.g. cardiac status) had little relevance to re-employment. The results are discussed with regard to the consequences for cardiac rehabilitation.

Psychological treatments in cardiac rehabilitation: review of rationales and outcomes

OBJECTIVE

In this review, the place of psychological interventions in cardiac rehabilitation and differences in underlying rationales are presented. Treatment approaches vary in that some practitioners favor biobehavioral approaches with strong relaxation/breathing components, whereas others offer unstructured support, psychoeducation to maximize compliance, or psychological interventions directed at reducing emotional distress.

METHODS

The effectiveness of psychosocial rehabilitation for endpoints like mortality, recurrence, emotional distress, and intermediate hard endpoints is reviewed by integrating conclusions from narrative and meta-analytic reviews as well as recent major clinical trials.

RESULTS

The aggregated findings support the use of psychosocial interventions and they also help to explain critical differences in outcome in that studies which fail to reduce distress also fail to lead to reduced mortality or reduced event recurrence.

CONCLUSION

Gender differences in outcome and recent trends in cardiology are discussed because both have distinct consequences for the effective delivery of psychological services to cardiac patients.

Effect of relaxation therapy on cardiac events after myocardial infarction: a 5-year follow-up study

BACKGROUND

Evidence suggests that breathing and relaxation therapy may influence cardiac events in persons after acute myocardial infarction (MI). The authors studied the effects of breathing and relaxation therapy on rates of cardiac events and cost effectiveness in past MI patients.

METHODS

Patients (n = 156) were chosen randomly to receive either exercise training plus relaxation therapy (relaxation group; n = 76) or exercise training only (control group; n = 80). The occurrence of major cardiac events and cardiac rehospitalizations in the two treatment groups was compared.

RESULTS

At 5-year follow-up, 12 cardiac deaths had occurred, 5 in the relaxation group and 7 in the control group, reinfarction occurred in 10 and 12 patients, and cardiac surgery was performed in 2 and 11, respectively. In total, 15 (20%) and 26 (33%) patients, respectively, experienced at least one cardiac event (odds ratio [OR] for the relaxation group: 0.55, 95% confidence interval [CI] 0.29-1.05; adjusted for risk factors OR 0.52, 95% CI 0.28-0.99). Regarding all cardiac rehospitalizations, in the relaxation group, 30 patients (39%) had experienced 52 cardiac events, for which the patients were hospitalized for a total of 476 days. In the control group, 38 patients (48%) had experienced 78 cardiac events (OR 0.72; 95% CI 0.38-1.36), comprising 719 days of hospitalization. The total number of hospitalizations was reduced by 31% as a result of relaxation instruction.

CONCLUSIONS

In the long-term, the disease course after myocardial infarction is influenced favorably by giving relaxation therapy in addition to cardiac rehabilitation. The extra costs of the therapy are compensated by a decrease in hospitalization for cardiac problems.

Psychosocial outcome assessments for use in cardiac rehabilitation service evaluation: a 10-year systematic review

A variety of measures are currently used to assess psychosocial outcome (quality of life) in cardiac rehabilitation programmes. However, there is no consensus on the most appropriate instruments to use. Instruments that are not sufficiently responsive to change in cardiac populations are unsuitable as audit tools as they underrepresent the benefits of programme attendance. To identify the most responsive instruments in cardiac rehabilitation populations a systematic overview of studies for the 10-year period 1986-1995 was conducted. The following databases were searched: Medline, Psychlit, Cinahl and Sociofile and 32 relevant studies were identified. The effect size statistic (a comparison of the magnitude of change to the variability in baseline scores) was used to determine those instruments most responsive to change. The following instruments were identified as being responsive in more than one study: Beck Depression Inventory, Global Mood Scale, Health Complaints Checklist, Heart Patients Psychological Questionnaire and Speilberger State Anxiety Inventory. There is little consensus on psychosocial evaluation instrument use in the cardiac rehabilitation literature. A number of measures show significant potential for routine outcome assessment. Formal assessment of these instruments is recommended to inform final recommendations about instrument selection for audit and evaluation purposes in cardiac rehabilitation.

Quality of life and anxiety in a phase II cardiac rehabilitation program

PURPOSE

Cardiac rehabilitation programs increasingly attempt to improve both quantity and quality of life (QOL). Documenting QOL changes requires appropriate instruments, and interpreting QOL data requires an understanding of the factors that influence such reports.

METHODS

To address both issues, we assessed QOL among 77 patients before and after participation in a 12-wk phase II cardiac rehabilitation program. Individual psychological differences in trait anxiety and defensiveness were also assessed. The sample was 76.6% male, 70.1% married, and had a mean age of 58.8 yr.

RESULTS

The QOL scales detected changes which occurred over the 12-wk testing period. QOL reports were strongly and differentially influenced by individual differences in trait anxiety, such that patients reporting high trait anxiety displayed poorer QOL than those low in trait anxiety. More specifically, trait anxiety influenced affect reports most strongly, functional aspects moderately, and physical aspects of QOL reports the least.

CONCLUSIONS

Defensiveness was unrelated to QOL reports. The 17% of participants who voluntarily left the rehabilitation program prematurely were characterized as younger, having better self-perceived health, having a less severe cardiac history, and being high in both trait anxiety and defensiveness. Study benefits and limitations are discussed.

Evidence for the effectiveness of cardiac rehabilitation

Cardiac rehabilitation is a relatively recent development and, though it is increasingly being recognized as an important part of comprehensive cardiac care, there remains some scepticism regarding its effectiveness and some ignorance of its potential. This article reviews the literature pertaining to the effectiveness of cardiac rehabilitation for patients with coronary heart disease (CHD).

Depression and coronary heart disease: observations and questions

The evidence that depressive symptomatology precedes the onset of the acute coronary syndromes and influences the course of disease after their manifestation is accumulating. However, we still are far short of proof that depression has a causal role in the etiology and pathogenesis of coronary heart disease (CHD). Some unsolved questions concern the causes and the nature of the depression preceding a first or recurrent cardiac event, the biological mechanisms relating depression and CHD, the time window of the exposure-disease association, and the power of therapy programs for depression to reduce the risk of a first or recurrent cardiac event.

The effect of a psychological intervention program on the risk of a new coronary event after angioplasty: a feasibility study

Restenosis after successful percutaneous coronary angioplasty (PTCA) is a major problem because it occurs in 25% to 35% of all patients. Because psychological factors, especially anger and vital exhaustion, have been found to increase the risk of new cardiac events after PTCA, a behavioral intervention might contribute to the reduction of the risk of restenosis. To investigate the operational and methodological aspects of a behavioral intervention, and to estimate the effect size of the risk reduction, we did a feasibility study of angioplasty patients who remained exhausted after PTCA. Breathing therapy was used as the main method for intervention. Thirty patients who participated in the intervention program and 65 controls were followed during an average period of 16 and 18 months, respectively. It was observed that the intervention resulted in a significant decrease of the mean exhaustion scores and reduced the risk of a new coronary event (cardiac death, coronary artery bypass grafting, myocardial infarction, rePTCA, restenosis) by 50% (chi = 2.19; p = 0.13). These results indicate that a clinical trial to test the hypothesis that a reduction of vital exhaustion and hostility reduces the risk of a new cardiac event after PTCA, is feasible and merits the efforts required.

Modification of physical activity 5 months after myocardial infarction: relevance of biographic and personality characteristics

The relation between modification of physical activity, a risk factor for coronary heart disease, and personality characteristics was assessed in 166 survivors of a first myocardial infarction (MI). Physical activity was assessed before MI in retrospect and again 5 months after MI. Patients were divided into 3 categories according to their current daily-life physical activities: less active than before MI (n=24), equally active as before MI (n=82), or more active than before MI (n=60). A significant differentiation was found between patients who became less physically active than before MI and the other 2 categories. This less active category was characterized by feelings of disability, a low level of vigor, and feelings of anxiety. In addition, this patient group was on average older and more often female. The results were adjusted for participation in a cardiac rehabilitation program. Finally, the discussion recommends involving psychological intervention in the exercise program for the less active category of patients to diminish feelings of anxiety and disability and to improve vigor.

Effects of relaxation intervention in phase II cardiac rehabilitation: replication and extension

OBJECTIVES

To examine the effects of progressive muscle relaxation and guided imagery on psychological and physiologic outcomes in adults with cardiovascular disease who were participating in a phase II cardiac rehabilitation program. To examine tension levels, practice patterns, and perceived helpfulness of the intervention reported by subjects.

DESIGN

Prospective, quasi-experimental, with random group assignment within sites. Independent replication and extension of a study by Bohachik (1984).

SETTING

Four midwestern hospital-based phase II cardiac rehabilitation programs.

PATIENTS

Fifty patients who within the preceding 12 weeks had had acute myocardial infarction or coronary artery bypass surgery or both, studied during 6 weeks of participation in a phase II cardiac rehabilitation program.

OUTCOME MEASURES

Psychological measures included state and trait anxiety scores on the State-Trait Anxiety Inventory and reported symptoms on the Symptom Checklist-90-Revised. Physiologic measures were resting heart rate and blood pressure. Subjective tension levels before and after home practice, practice patterns, and perceived helpfulness of the intervention were examined.

INTERVENTION

Individual instruction session in progressive muscle relaxation and guided imagery at the phase II cardiac rehabilitation program, followed by daily home practice with audiotape instructions over a 6-week period.

RESULTS

No statistical differences at the p < or = 0.05 level were found in state anxiety scores or reported symptoms at study exit. However, reductions in mean subscale scores for interpersonal sensitivity (t [19] = 2.11, p < or = 0.05) and depression (t [19] = 2.07, p < or = 0.05) by paired t tests were found for the relaxation group (RG). The two groups differed at study exit in resting heart rate (t [42] = -2.02, p < or = 0.05) by independent t tests and in systolic blood pressure (F [1,42] = 5.13, p < or = 0.05) by analysis of covariance. The RG had a mean resting heart rate 8.6 beats/min lower than that of the control group (CG) and also had within-group reductions in mean heart rate (t [19] = 2.09, p < or = 0.05) by paired t tests. Contrary to expectation, the CG had a 3.5 mm Hg lower mean systolic blood pressure and within-group reductions in systolic (t [22] = 3.02, p < 0.01) and diastolic (t [22] = 3.83, p < 0.01) blood pressure by paired t tests. CG subjects had a greater number of dose increases in cardiac medications and fewer dose reductions than did RG subjects, who also had a higher number of dose reductions. RG subjects reported frequent practice of the technique, rated it as helpful, and reported lower subjective tension levels after practice.

CONCLUSIONS

Findings in this study did not support those of Bohachik (who reported lowered state anxiety and fewer somatization, interpersonal sensitivity, and depression symptoms). More instruction sessions on the relaxation method may have resulted in more positive outcomes. However, the within-group scores for interpersonal sensitivity and depression, the reduction in heart rate, and the receptivity of subjects to this intervention suggest that it may be a feasible and helpful adjunctive therapy for participants in a phase II cardiac rehabilitation program.

Psychological rehabilitation after myocardial infarction: multicentre randomised controlled trial

OBJECTIVE

To evaluate rehabilitation after myocardial infarction.

DESIGN

Randomised controlled trial of rehabilitation in unselected myocardial infarction patients in six centres, baseline data being collected on admission and by structured interview (of patients and spouses) shortly after discharge and outcome being assessed by structured interview at six months and clinical examination at 12 months.

SETTING

Six district general hospitals.

SUBJECTS

All 2328 eligible patients admitted over two years with confirmed myocardial infarction and discharged home within 28 days.

INTERVENTIONS

Rehabilitation programmes comprising psychological therapy, counselling, relaxation training, and stress management training over seven weekly group outpatient sessions for patients and spouses.

MAIN OUTCOME MEASURES

Anxiety, depression, quality of life, morbidity, use of medication, and mortality.

RESULTS

At six months there were no significant differences between rehabilitation patients and controls in reported anxiety (prevalence 33%) or depression (19%). Rehabilitation patients reported a lower frequency of angina (median three versus four episodes a week), medication, and physical activity. At 12 months there were no differences in clinical complications, clinical sequelae, or mortality.

CONCLUSIONS

Rehabilitation programmes based on psychological therapy, counselling, relaxation training, and stress management seem to offer little objective benefit to patients who have experienced myocardial infarction compared with previous reports of smaller trials.

Quality of life in cardiac patient research: a meta-analysis

This article reports a meta-analysis of 84 studies of quality of life (QOL) in cardiac patient populations published in the 5-year period 1987-1991. Selected methodologies and substantive characteristics of the studies are described. An overall effect size of .31 indicated a small but significant positive effect of pharmacologic, mechanical, surgical, nursing, or other treatment on QOL. No negative effect of treatment was found for any cardiovascular diagnostic category. Homogeneity analysis revealed eight potential moderators of the overall effect size: quality of study, gender of sample, time dimension, sampling method, intervention, marital status of subjects, quality-of-life dimension measured, and sample size.

Stress management in cardiac patients: a preliminary study of the predictors of improvement in quality of life

The effects on quality of life of a 12-wk relaxation-based stress management programme emphasizing improvements in self-confidence and control was assessed in seventy-eight patients following myocardial infarction, coronary artery bypass surgery or coronary angioplasty. Measures of psychological state, functional mobility level, social activity and chest pain were obtained before and after treatment and at 6 month follow-up. Fifty-one (66%) of patients completed the programme. Significant reductions in anxiety and depression and improvements in psychological general well-being, activities of daily living, social activity, quality of interactions and satisfaction with sexual relationships were observed posttreatment, and these were largely maintained at follow-up. Reductions in chest pain and improvements in spouse ratings of psychological state were also recorded. Similar responses were measured in myocardial infarction and surgery patients. Predictors of outcome in three aspects of quality of life, anxiety, activities of daily living and social activity, were assessed. Improvements in these three domains were independent of one another, and their predictors were also different. Reductions in anxiety were associated with neurotic dispositions and openness to new experience, while improvements in activities of daily living were predicted by work status, age and time since infarction or surgery. Implications for the use of stress management in cardiac rehabilitation are discussed.

Changes in life-style in men under sixty years of age before and after acute myocardial infarction: a case-control study

A case-control study was conducted to examine the presence of psychosocial factors before, during, and after acute myocardial infarction (AMI) in Dutch men under sixty years of age. The study included 42 AMI patients and 48 individuals in an age-adjusted sampled control group. The psychological factors included high level of psychological stress, of social isolation, type A1 and A2 behavior, and mental depression. They were assessed by means of the Health Insurance Questionnaire of Greater New York. Univariate analysis indicated that the presence of psychological factors was common at the onset of the myocardial infarction (MI). It clearly diminished, however, after the MI had taken place. In a stepwise logistic regression analysis after adjustment for the independent variables hypertension, cholesterol, and smoking, the following three characteristics were independently related to the risk of MI: no talking (item of social isolation, P = 0.008), need to excel (item of type A1 behavior, P = 0.04), and blue feeling (item of mental depression, P = 0.09). The authors conclude that in men under 60 with AMI, the presence of psychosocial characteristics is common and that this group is going to change its life-style soon after the MI, even without any psychosocial rehabilitation therapy. Follow-up studies investigating the influence of psychological factors on survival and reinfarction should be adjusted for these changes in life-style.

Predictability of psychic outcome for exercise training and exercise training including relaxation therapy after myocardial infarction

Predictability of the psychic outcome for two cardiac rehabilitation programmes was investigated in 119 myocardial infarction patients. They were randomly assigned to either a five-week daily exercise training or to an identical training in combination with six sessions of relaxation therapy, individually. The psychic outcome was constructed as a composite measure of change on six psychological questionnaires. The aim was to determine the predictive qualities of base-line: (1) clinical data; (2) exercise testing; (3) psychosocial information derived from interview; and (4) validated psychological questionnaires and whether the kind of rehabilitation programme has any influence on the predictive qualities of the variables. The psychic outcome turned out to be highly predictable (multiple correlation of 0.72). Predictors of relatively high importance were age, work-status and job-level, followed by mild heart failure, diastolic blood pressure and heart rate, all of them dependent upon the kind of treatment. It implies that the type of rehabilitation programme modified the effect of the determinants of psychic outcome. This research strategy is promising and deserves to be stimulated in order to build rehabilitation programmes tailored to the needs and abilities of the individual patient.

Success and failure of exercise training after myocardial infarction: is the outcome predictable?

One hundred fifty-six patients underwent a 5 week daily exercise training program after recovery from acute myocardial infarction. Outcome was assessed on the basis of exercise testing, integrating the measurements into a single outcome measure consisting of three categories (positive, n = 79; negative, n = 42; no change, n = 35). This composite criterion served as the end point for determining the predictability of a positive (training success) and negative (training failure) outcome. With use of logistic regression analysis, the baseline variables of clinical information, exercise data and psychosocial variables were able to identify patients with training success, as well as patients with failure (correct classification rates 81% and 85%, respectively). The characteristics of patients for whom training was beneficial differed from those of patients with a negative outcome. Work status before infarction was the single most important predictor of success, but it did not determine failure. Psychologic variables (type A behavior, well-being, depression) were important for predicting failure, but not for predicting success. Cardiac state and physical fitness largely determined training success. It is concluded that the physical benefit of exercise training in patients after myocardial infarction is highly predictable. Validation will make it possible to optimally apply exercise training as a therapeutic modality in these patients.