The effects of a tailored cardiac rehabilitation program on depressive symptoms in women: A randomized clinical trial

Psychological interventions targeting mental health and stress among females with cardiac disease: a scoping review

Interventions that target mental health symptoms and stress among those with established cardiac disease have included predominately male samples despite female patients reporting greater severity of these symptoms. The aim of this scoping review was to synthesize the published literature on psychological interventions for females with cardiac disease. We conducted a systematic search of peer-reviewed randomized clinical trials (RCTs) published in the English language from 2003 to 2023, in three databases: Medline (Ovid), PsycInfo (Ovid), and CINAHL (EBSCO). Articles that included female samples, a control or comparison group, implemented psychological interventions, and measured depression, anxiety, or stress as an outcome were included in the review. Nine articles describing eight RCTs of psychological interventions, with a total of 1587 female patients with cardiac disease, were included. Interventions were most successful at reducing stress (75% of studies measuring stress reported efficacy), while symptoms of depression and anxiety were less responsive to intervention (∼30% of studies targeting these symptoms reported improvements) in comparison to a control condition. This scoping review highlights that further advancement in knowledge is required to better address the needs of females with cardiac disease and distress, particularly depression and anxiety.

Predictors of Health-Related Quality of Life Among Women Participating in an Appointment-Based Cardiac Rehabilitation Program

BACKGROUND

An alternative patient-centered appointment-based cardiac rehabilitation (CR) program has led to significant improvements in health outcomes for patients with cardiovascular disease. However, less is known about the effects of this approach on health-related quality of life (HRQoL), particularly for women.

OBJECTIVE

We examined the effects of a patient-centered appointment-based CR program on HRQoL by sex and examined predictors of HRQoL improvements specifically for women.

METHODS

Data were used from an urban single-center CR program at Yale New Haven Health (2012-2017). We collected information on patient demographics, socioeconomic status, and clinical characteristics. The Outcome Short-Form General Health Survey (SF-36) was used to measure HRQoL. We evaluated sex differences in SF-36 scores using t tests and used a multivariate linear regression model to examine predictors of improvements in HRQoL (total SF-36 score) for women.

RESULTS

A total of 1530 patients with cardiovascular disease (23.7% women, 4.8% Black; mean age, 64 ± 10.8 years) were enrolled in the CR program. Women were more likely to be older, Black, and separated, divorced, or widowed. Although women had lower total SF-36 scores on CR entry, there was no statistically significant difference in CR adherence or total SF-36 score improvements between sexes. Women who were employed and those with chronic obstructive pulmonary disease were more likely to have improvements in total SF-36 scores.

CONCLUSION

Both men and women participating in an appointment-based CR program achieved significant improvements in HRQoL. This approach could be a viable alternative to conventional CR to optimize secondary outcomes for patients.

Mapping interventional components and behavior change techniques used to promote self-management in people with multimorbidity: a scoping review

Ageing populations and improved survival, have contributed to a rise in the number of people living with multimorbidity, raising issues related to polypharmacy, treatment burden, competing priorities and poor coordination of care. Self-management programs are increasingly included as an essential component of interventions to improve outcomes in this population. However, an overview of how interventions supporting self-management in patients with multimorbidity is missing. This scoping review focused on mapping the literature on patient-centered interventions for people living with multimorbidity. We searched several databases, clinical registries, and grey literature for RCTs published between 1990-2019 describing interventions that supported self-management in people with multimorbidity. We included 72 studies that were found to be very heterogeneous when it comes to the population, delivery modes and modalities, intervention elements and facilitators. The results pointed to an extensive use of cognitive behavioral therapy as a basis for interventions, as well as behavior change theories and disease management frameworks. The most coded behavior change techniques stemmed from the categories Social Support, Feedback and monitoring and Goals and Planning. To allow for implementation of effective interventions in clinical practice, improved reporting of intervention mechanisms in RCTs is warranted.

A Mobile Health Behavior Change Intervention for Women With Coronary Heart Disease: A RANDOMIZED CONTROLLED PILOT STUDY

PURPOSE

The aim of this study was to evaluate the effects of a mobile health (mHealth) intervention, HerBeat, compared with educational usual care (E-UC) for improving exercise capacity (EC) and other patient-reported outcomes at 3 mo among women with coronary heart disease.

METHODS

Women were randomized to the HerBeat group (n = 23), a behavior change mHealth intervention with a smartphone, smartwatch, and health coach or to the E-UC group (n = 24) who received a standardized cardiac rehabilitation workbook. The primary endpoint was EC measured with the 6-min walk test (6MWT). Secondary outcomes included cardiovascular disease risk factors and psychosocial well-being.

RESULTS

A total of 47 women (age 61.2 ± 9.1 yr) underwent randomization. The HerBeat group significantly improved on the 6MWT from baseline to 3 mo ( P = .016, d = .558) while the E-UC group did not ( P = .894, d =-0.030). The between-group difference of 38 m at 3 mo was not statistically significant. From baseline to 3 mo, the HerBeat group improved in anxiety ( P = .021), eating habits confidence ( P = .028), self-efficacy for managing chronic disease ( P = .001), diastolic blood pressure ( P = .03), general health perceptions ( P = .047), perceived bodily pain ( P = .02), and waist circumference ( P = .008) while the E-UC group showed no improvement on any outcomes.

CONCLUSIONS

The mHealth intervention led to improvements in EC and several secondary outcomes from baseline to 3 mo while the E-UC intervention did not. A larger study is required to detect small differences between groups. The implementation and outcomes evaluation of the HerBeat intervention was feasible and acceptable with minimal attrition.

Exercise-based cardiac rehabilitation in women with heart failure: a review of enrollment, adherence, and outcomes

Exercise-based cardiac rehabilitation (CR) is an evidence-based recommendation for patients with stable heart failure (HF). Less clear is how effective exercise-based CR is for women with HF. The aim of this review was to synthesize the evidence for the effects of exercise-based CR on mortality, hospitalizations, exercise capacity, and quality of life (QOL) among women with HF. We identified 18 studies comprising 4917 patients, of which 1714 were women. The interventions evaluated consisted of various combinations of supervised in-hospital and out-patient sessions as well as home-based programs that included aerobic (walking, treadmill, bicycle) and resistance training. The interventions ranged from 12 to 54 weeks, with a frequency of 2-7 sessions per week, lasting from 30 to 105 min per session. Because of a paucity of sex-specific analyses of the outcomes, it was not possible to draw conclusions for women. There was limited evidence for mortality benefit for men or women participating in exercise-based CR. There was more substantial evidence for reductions in hospitalizations for the participants. Generally, exercise training improved exercise capacity. The effects of exercise-based CR on QOL were mixed with most studies favoring CR at 3 months but not at 4, 5, and 12 months. Moreover, generally, the physical dimension of QOL but not the mental dimensions improved. Recommendations for future research to reduce the gap in knowledge about the effects of exercise-based CR for women are offered.

Feasibility of Integrating MEditatioN inTO heaRt Disease (the MENTOR Study): A Phase II Randomized Controlled Trial

BACKGROUND

Comorbid depression and/or anxiety symptoms occur in 25% of patients attending cardiac rehabilitation (CR) programs and are associated with poorer prognosis. There is a need to evaluate psychological interventions, including meditation, that have potential to improve psychological health in CR programs.

AIMS

The aim of this study was to determine the feasibility and acceptability of integrating a meditation intervention into an existing Australian CR program for the reduction of depression and anxiety symptoms.

METHODS

This was a mixed-methods feasibility randomized controlled trial. Thirty-one patients with CVD and, at a minimum, mild depression and/or anxiety symptoms were randomized to meditation and standard CR or to standard CR alone. A 16-minute guided group meditation was delivered face-to-face once a week for 6 weeks, with daily self-guided meditation practice between sessions. Feasibility outcomes included screening, recruitment, and retention. Semistructured interviews of patients' (n = 10) and health professionals' (n = 18) perspectives of intervention participation and delivery were undertaken to assess acceptability. Between-group differences in depression, anxiety, stress, self-efficacy for mindfulness, and health status at 6 and 12 weeks were also assessed.

RESULTS AND CONCLUSION

Meditation was considered feasible, with 83% (12/15) of the intervention group completing an average of 3.13 (SD, 2.56) out of 6 group meditation sessions and 5.28 (SD, 8.50) self-guided sessions. Meditation was considered acceptable by patients, clinicians, and health managers. Between-group differences in the number of CR sessions completed favored the intervention group in per-protocol analyses (intervention group vs control group, 12 vs 9 sessions; P = .014), which suggests that meditation may be useful to improve patients' adherence to exercise-based CR program.

Women-Focused Cardiovascular Rehabilitation: An International Council of Cardiovascular Prevention and Rehabilitation Clinical Practice Guideline

Women-focused cardiovascular rehabilitation (CR; phase II) aims to better engage women, and might result in better quality of life than traditional programs. This first clinical practice guideline by the International Council of Cardiovascular Prevention and Rehabilitation (ICCPR) provides guidance on how to deliver women-focused programming. The writing panel comprised experts with diverse geographic representation, including multidisciplinary health care providers, a policy-maker, and patient partners. The guideline was developed in accordance with Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Reporting Items for practice Guidelines in HealTh care (RIGHT). Initial recommendations were on the basis of a meta-analysis. These were circulated to a Delphi panel (comprised of corresponding authors from review articles and of programs delivering women-focused CR identified through ICCPR's audit; N = 76), who were asked to rate each on a 7-point Likert scale in terms of impact and implementability (higher scores positive). A Web call was convened to achieve consensus; 15 panelists confirmed strength of revised recommendations (Grading of Recommendations Assessment, Development, and Evaluation [GRADE]). The draft underwent external review from CR societies internationally and was posted for public comment. The 14 drafted recommendations related to referral (systematic, encouragement), setting (model choice, privacy, staffing), and delivery (exercise mode, psychosocial, education, self-management empowerment). Nineteen (25.0%) survey responses were received. For all but 1 recommendation, ≥ 75% voted to include; implementability ratings were < 5/7 for 4 recommendations, but only 1 for effect. Ultimately 1 recommendation was excluded, 1 separated into 2 and all revised (2 substantively); 1 recommendation was added. Overall, certainty of evidence for the final recommendations was low to moderate, and strength mostly strong. These recommendations and associated tools can support all programs to feasibly offer some women-focused programming.

Outcomes and cost of women-focused cardiac rehabilitation: A systematic review and meta-analysis

BACKGROUND

The aim of this systematic review was to investigate the effects of women-focused cardiac rehabilitation (CR) on patient outcomes and cost.

METHODS

Medline, PubMed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception through to May 2020. Primary studies of any design were included, with adult females with any cardiac diseases. "Women-focused" CR comprised programs or sessions with >50% females, or 1-1 programming tailored to women's preferences. No studies were excluded on the basis of outcome. Two independent reviewers rated citations for potential inclusion, and one extracted data, including on quality, which was checked independently. Random-effects meta-analysis was used where there were ≥3 trials with the same outcome; certainty of evidence for these was determined based on GRADE. For other outcomes, SWiM was applied.

RESULTS

3498 unique citations were identified, of which 28 studies (52 papers) were included (3,697 participants; 11 trials). No meta-analysis could be performed for outcomes with "usual care" comparisons. Compared to "active comparison" group, women-focused CR had no meaningful additional effect on functional capacity. Women-focused CR meaningfully improved physical (mean difference [MD]=6.37, 95% confidence interval [CI]=3.14-9.59; I2=0%; moderate-quality evidence) and mental (MD=4.66, 95% CI=0.21-9.11; I2=36%; low-quality evidence) quality of life, as well as scores on seven of the eight SF-36 domains. Qualitatively, results showed women-focused CR was associated with lower morbidity, risk factors, and greater psychosocial well-being. No effect was observed for mortality. One study reported a favorable economic impact and another reported reduced sick days.

CONCLUSIONS

Women-focused CR is associated with clinical benefit, although there is mixed evidence and more research is needed.

PROSPERO REGISTRATION

CRD42020189760.

Adaptive web-based stress management programs among adults with a cardiovascular disease: A pilot Sequential Multiple Assignment Randomized Trial (SMART)

OBJECTIVE

To assess the feasibility and acceptability of using a Sequential Multiple Assignment Randomized Trial (SMART) to optimize the delivery of a web-based, stress management intervention for patients with a cardiovascular disease (CVD).

METHODS

59 patients with a CVD and moderate stress were randomized to a self-directed web-based stress management program (n = 30) or the same intervention plus lay telephone coaching (n = 29). After 6 weeks, non-responders were re-randomized to continue with their initial intervention or switched to motivational interviewing (MI). Feasibility, acceptability, and clinical significance were assessed.

RESULTS

SMART procedures were feasible. Attrition rates were almost twice as high in the web-only group than the lay coach group. This might be because of the low satisfaction (47%) in the web-only group. On average, 1.7/5 modules were completed. Effect sizes for stress and quality of life generally exceeded 0.2 (clinical benchmark), except for the group that initially received lay coaching and then switched to MI.

CONCLUSIONS

Results suggest that a larger trial would be feasible. Issues pertaining to attrition and satisfaction for non-responders need to be addressed.

PRACTICE IMPLICATIONS

Findings contribute to the evidence on how best to develop and deliver e-Health interventions to maximize their efficacy while remaining cost-effective.

Sex Differences in Cardiac Rehabilitation Outcomes

Cardiovascular disease is a leading cause of morbidity and mortality in males and females in the United States and globally. Cardiac rehabilitation (CR) is recommended by the American Heart Association/American College of Cardiology for secondary prevention for patients with cardiovascular disease. CR participation is associated with improved cardiovascular disease risk factor management, quality of life, and exercise capacity as well as reductions in hospital admissions and mortality. Despite these advantageous clinical outcomes, significant sex disparities exist in outpatient phase II CR programming. This article reviews sex differences that are present in the spectrum of care provided by outpatient phase II CR programming (ie, from referral to clinical management). We first review CR participation by detailing the sex disparities in the rates of CR referral, enrollment, and completion. In doing so, we discuss patient, health care provider, and social/environmental level barriers to CR participation with a particular emphasis on those barriers that majorly impact females. We also evaluate sex differences in the core components incorporated into CR programming (eg, patient assessment, exercise training, hypertension management). Next, we review strategies to mitigate these sex differences in CR participation with a focus on automatic CR referral, female-only CR programming, and hybrid CR. Finally, we outline knowledge gaps and areas of future research to minimize and prevent sex differences in CR programming.

Cardiac rehabilitation in women, challenges and opportunities

Cardiac rehabilitation(CR) has known proven benefits in reducing mortality related to cardiovascular disease (CVD), improving quality of life (QoL), and preventing CVD-related readmissions. Despite these known benefits, CR remains underutilized among women relative to men. Disparities exist at the level of referral, enrollment, and program completion. Much is left to be understood regarding the utility of CR in female-predominant CVD such as postpartum cardiomyopathy and Spontaneous Coronary Artery Dissection. This review identifies the benefits of CR for specific populations of women and elucidates on the barriers to CR. We also describe current recommendations to overcome barriers to CR in women.

Women's outcomes following mixed-sex, women-only, and home-based cardiac rehabilitation participation and comparison by sex

BACKGROUND

Despite women's greater need for cardiac rehabilitation (CR), they are less likely to utilize it. Innovative CR models have been developed to better meet women's needs, yet there is little controlled, comparative data assessing the effects of these models for women. This study compared outcomes in women electing to participate in mixed-sex, women-only, or home-based CR, and a matched sample of men.

METHODS

In this retrospective study, electronic records of CR participants in Toronto who were offered the choice of program model between January 2017 and July 2019 were analyzed; clinical outcomes comprised cardiorespiratory fitness, risk factors and psychosocial well-being. These were assessed at intake and post-6-month program and analyzed using general linear mixed models.

RESULTS

There were 1181 patients (727 women [74.7% mixed, 22.0% women-only, 3.3% home-based]; 454 age and diagnosis-matched men) who initiated CR; Cardiorespiratory fitness among women was higher at initiation of mixed-sex than women-only (METs 5.1 ± 1.5 vs 4.6 ± 1.3; P = .007), but no other outcome differences were observed. 428 (58.9%) women completed the programs, with few women retained in the home-based model limiting comparisons. There were significant improvements in high-density lipoprotein cholesterol (P = .001) and quality of life (P = .001), and lower depressive symptoms (P = .030) as well as waist circumference (P = .001) with mixed-sex only. VO2peak was significantly higher at discharge in mixed-sex than women-only (estimate = 1.67, standard error = 0.63, 95% confidence interval = 0.43-2.91).

CONCLUSION

Participation in non-gender-tailored women-only CR was not advantageous as expected. More research is needed, particularly including women participating in home-based programs.

Nature, availability, and utilization of women-focused cardiac rehabilitation: a systematic review

Background

Women do not participate in cardiac rehabilitation (CR) to the same degree as men; women-focused CR may address this. This systematic review investigated the: (1) nature, (2) availability, as well as (3a) utilization of, and (b) satisfaction with women-focused CR.

Methods

Medline, Pubmed, Embase, PsycINFO, CINAHL, Web of Science, Scopus and Emcare were searched for articles from inception to May 2020. Primary studies of any design were included. Adult females with any cardiac diseases, participating in women-focused CR (i.e., program or sessions included ≥ 50% females, or was 1-1 and tailored to women’s needs) were considered. Two authors rated citations for inclusion. One extracted data, including study quality rated as per the Mixed-Methods Assessment Tool (MMAT), which was checked independently by a second author. Results were analyzed in accordance with the Synthesis Without Meta-analysis (SWiM) reporting guideline.

Results

3498 unique citations were identified, with 28 studies (53 papers) included (3697 women; ≥ 10 countries). Globally, women-focused CR is offered by 40.9% of countries that have CR, with 32.1% of programs in those countries offering it. Thirteen (46.4%) studies offered women-focused sessions (vs. full program), 17 (60.7%) were women-only, and 11 (39.3%) had gender-tailoring. Five (17.9%) programs offered alternate forms of exercise, and 17 (60.7%) focused on psychosocial aspects. With regard to utilization, women-focused CR cannot be offered as frequently, so could be less accessible. Adherence may be greater with gender-tailored CR, and completion effects are not known. Satisfaction was assessed in 1 trial, and results were equivocal.

Conclusions

Women-focused CR involves tailoring of content, mode and/or sex composition. Availability is limited. Effects on utilization require further study.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02267-0.

A Mobile Health Intervention System for Women With Coronary Heart Disease: Usability Study

Background

Coronary heart disease (CHD) is the leading cause of death and disability among American women. The prevalence of CHD is expected to increase by more than 40% by 2035. In 2015, the estimated cost of caring for patients with CHD was US $182 billion in the United States; hospitalizations accounted for more than half of the costs. Compared with men, women with CHD or those who have undergone coronary revascularization have up to 30% more rehospitalizations within 30 days and up to 1 year. Center-based cardiac rehabilitation is the gold standard of care after an acute coronary event, but few women attend these valuable programs. Effective home-based interventions for improving cardiovascular health among women with CHD are vital for addressing this gap in care.

Objective

The ubiquity of mobile phones has made mobile health (mHealth) behavioral interventions a viable option to improve healthy behaviors of both women and men with CHD. First, this study aimed to examine the usability of a prototypic mHealth intervention designed specifically for women with CHD (herein referred to as HerBeat). Second, we examined the influence of HerBeat on selected health behaviors (self-efficacy for diet, exercise, and managing chronic illness) and psychological (perceived stress and depressive symptoms) characteristics of the participants.

Methods

Using a single-group, pretest, posttest design, 10 women participated in the 12-week usability study. Participants were provided a smartphone and a smartwatch on which the HerBeat app was installed. Using a web portal dashboard, a health coach monitored participants’ ecological momentary assessment data, their behavioral data, and their heart rate and step count. Participants then completed a 12-week follow-up assessment.

Results

All 10 women (age: mean 64.4 years, SD 6.3 years) completed the study. The usability and acceptability of HerBeat were good, with a mean system usability score of 83.60 (SD 16.3). The participants demonstrated statistically significant improvements in waist circumference (P=.048), weight (P=.02), and BMI (P=.01). Furthermore, depressive symptoms, measured with the Patient Health Questionnaire-9, significantly improved from baseline (P=.04).

Conclusions

The mHealth prototype was feasible and usable for women with CHD. Participants provided data that were useful for further development of HerBeat. The mHealth intervention is expected to help women with CHD self-manage their health behaviors. A randomized controlled trial is needed to further verify the findings.

Care of the Post-CABG Patient

An estimated 400,000 coronary artery bypass graft operations are performed annually in the United States. Saphenous vein grafts are the most commonly used conduits; however, graft failure is common. In contrast, left internal mammary artery grafts have more favorable long-term patency rates. Guidelines recommend aggressive secondary prevention. In the 2 decades following surgery, 16% of patients require repeat revascularization, and percutaneous coronary intervention accounts for 98% of procedures performed. Post-coronary artery bypass graft patients presenting with symptoms of acute coronary syndrome or progressive heart failure should undergo early coronary angiography given the high likelihood that such a presentation represents graft failure. Percutaneous coronary intervention in degenerated saphenous vein grafts is associated with embolization that may cause the "no-reflow phenomenon," which can be avoided with the use of embolic protection devices. Hybrid revascularization procedures are a promising emerging strategy to avoid the placement of vein grafts.

A Systematic Review of the Diagnostic Accuracy of Depression Questionnaires for Cardiac Populations: IMPLICATIONS FOR CARDIAC REHABILITATION

PURPOSE

Depression is overrepresented in patients with cardiovascular disease and increases risk for future cardiac events. Despite this, depression is not routinely assessed within cardiac rehabilitation. This systematic review sought to examine available depression questionnaires to use within the cardiac population. We assessed each instrument in terms of its capability to accurately identify depressed patients and its sensitivity to detect changes in depression after receiving cardiac rehabilitation.

METHODS

Citation searching of previous reviews, MEDLINE, PsycInfo, and PubMed was conducted.

RESULTS

The Beck Depression Inventory-II (BDI-II) and the Hospital Anxiety and Depression Scale (HADS-D) are among the most widely used questionnaires. Screening questionnaires appear to perform better at accurately identifying depression when using cut scores with high sensitivity and specificity for the cardiac population. The BDI-II and the HADS-D showed the best sensitivity and negative predictive values for detecting depression. The BDI-II, the HADS-D, the Center for Epidemiological Studies-Depression Scale, and the 15-item Geriatric Depression Scale best captured depression changes after cardiac rehabilitation delivery.

CONCLUSIONS

The BDI-II is one of the most validated depression questionnaires within cardiac populations. Health practitioners should consider the BDI-II for depression screening and tracking purposes. In the event of time/cost constraints, a briefer 2-step procedure (the 2-item Patient Health Questionnaire, followed by the BDI-II, if positive) should be adopted. Given the emphasis on cut scores for depression diagnosis and limited available research across cardiac diagnoses, careful interpretation of these results should be done. Thoughtful use of questionnaires can help identify patients in need of referral or further treatment.

Interventions to promote patient utilisation of cardiac rehabilitation

BACKGROUND

International clinical practice guidelines routinely recommend that cardiac patients participate in rehabilitation programmes for comprehensive secondary prevention. However, data show that only a small proportion of these patients utilise rehabilitation.

OBJECTIVES

First, to assess interventions provided to increase patient enrolment in, adherence to, and completion of cardiac rehabilitation. Second, to assess intervention costs and associated harms, as well as interventions intended to promote equitable CR utilisation in vulnerable patient subpopulations.

SEARCH METHODS

Review authors performed a search on 10 July 2018, to identify studies published since publication of the previous systematic review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL); the National Health Service (NHS) Centre for Reviews and Dissemination (CRD) databases (Health Technology Assessment (HTA) and Database of Abstracts of Reviews of Effects (DARE)), in the Cochrane Library (Wiley); MEDLINE (Ovid); Embase (Elsevier); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); and Conference Proceedings Citation Index - Science (CPCI-S) on Web of Science (Clarivate Analytics). We checked the reference lists of relevant systematic reviews for additional studies and also searched two clinical trial registers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in adults with myocardial infarction, with angina, undergoing coronary artery bypass graft surgery or percutaneous coronary intervention, or with heart failure who were eligible for cardiac rehabilitation. Interventions had to aim to increase utilisation of comprehensive phase II cardiac rehabilitation. We included only studies that measured one or more of our primary outcomes. Secondary outcomes were harms and costs, and we focused on equity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of all identified references for eligibility, and we obtained full papers of potentially relevant trials. Two review authors independently considered these trials for inclusion, assessed included studies for risk of bias, and extracted trial data independently. We resolved disagreements through consultation with a third review author. We performed random-effects meta-regression for each outcome and explored prespecified study characteristics.

MAIN RESULTS

Overall, we included 26 studies with 5299 participants (29 comparisons). Participants were primarily male (64.2%). Ten (38.5%) studies included patients with heart failure. We assessed most studies as having low or unclear risk of bias. Sixteen studies (3164 participants) reported interventions to improve enrolment in cardiac rehabilitation, 11 studies (2319 participants) reported interventions to improve adherence to cardiac rehabilitation, and seven studies (1567 participants) reported interventions to increase programme completion. Researchers tested a variety of interventions to increase utilisation of cardiac rehabilitation. In many studies, this consisted of contacts made by a healthcare provider during or shortly after an acute care hospitalisation.Low-quality evidence shows an effect of interventions on increasing programme enrolment (19 comparisons; risk ratio (RR) 1.27, 95% confidence interval (CI) 1.13 to 1.42). Meta-regression revealed that the intervention deliverer (nurse or allied healthcare provider; P = 0.02) and the delivery format (face-to-face; P = 0.01) were influential in increasing enrolment. Low-quality evidence shows interventions to increase adherence were effective (nine comparisons; standardised mean difference (SMD) 0.38, 95% CI 0.20 to 0.55), particularly when they were delivered remotely, such as in home-based programs (SMD 0.56, 95% CI 0.37 to 0.76). Moderate-quality evidence shows interventions to increase programme completion were also effective (eight comparisons; RR 1.13, 95% CI 1.02 to 1.25), but those applied in multi-centre studies were less effective than those given in single-centre studies, leading to questions regarding generalisability. A moderate level of statistical heterogeneity across intervention studies reflects heterogeneity in intervention approaches. There was no evidence of small-study bias for enrolment (insufficient studies to test for this in the other outcomes).With regard to secondary outcomes, no studies reported on harms associated with the interventions. Only two studies reported costs. In terms of equity, trialists tested interventions designed to improve utilisation among women and older patients. Evidence is insufficient for quantitative assessment of whether women-tailored programmes were associated with increased utilisation, and studies that assess motivating women are needed. For older participants, again while quantitative assessment could not be undertaken, peer navigation may improve enrolment.

AUTHORS' CONCLUSIONS

Interventions may increase cardiac rehabilitation enrolment, adherence and completion; however the quality of evidence was low to moderate due to heterogeneity of the interventions used, among other factors. Effects on enrolment were larger in studies targeting healthcare providers, training nurses, or allied healthcare providers to intervene face-to-face; effects on adherence were larger in studies that tested remote interventions. More research is needed, particularly to discover the best ways to increase programme completion.

Optimal Gender-Specific Strategies for the Secondary Prevention of Heart Disease in Women: A SYSTEMATIC REVIEW

BACKGROUND

There is a paucity of evidence on gender-specific, individually tailored secondary prevention (cardiac rehabilitation [CR]) services for women with heart disease. Women participate less in CR programs, thus increasing their risk of further cardiac events. This review aims to (1) determine the effectiveness of gender-specific interventions specifically designed for women with heart disease, delivered in outpatient CR settings; and (2) classify key elements of effective CR strategies/models for women with heart disease.

METHODS

Using the PRISMA guidelines, this is a systematic review of CR models tailored to women to improve cardiovascular risk. Four databases were searched for randomized controlled trials (RCTs) between January 1974 and July 2017 published in peer-reviewed English language journals.

RESULTS

Three RCTs comprising 725 women of gender-specific CR strategies were identified. Significant improvements were found in one-third (1 study) of the included multicomponent CR strategies for outcomes including general health, social functioning, vitality, mental health, depression, and quality of life.

CONCLUSION

Further large-scale RCTs are required to replicate positive findings and accurately assess the capacity for gender-specific multicomponent CR programs that incorporate participant-driven collaborative models to moderate psychological risk and improve functional capacity and quality of life for women with heart disease.

Acute myocardial infarction in young women: current perspectives

Acute myocardial infarction (AMI) is the leading cause of death in women worldwide. Every year, in the USA alone, more than 30,000 young women <55 years of age are hospitalized with AMI. In recent decades, the incidence of AMI is increasing in younger women in the context of increasing metabolic syndrome, diabetes mellitus, and non-traditional risk factors such as stress, anxiety, and depression. Although women are classically considered to present with atypical chest pain, several observational data confirm that men and women experience similar rates of chest pain, with some differences in intensity, duration, radiation, and the choice of descriptors. Women also experience more number of symptoms and more prodromal symptoms compared with men. Suboptimal awareness, sociocultural and financial reasons result in pre-hospital delays in women and lower rates of access to care with resulting undertreatment with guideline-directed therapies. Causes of AMI in young women include plaque-related MI, microvascular dysfunction or vasospasm, and spontaneous coronary artery dissection. Compared with men, women have greater in-hospital, early and late mortality, as a result of baseline comorbidities. Post-AMI women have lower referral to cardiac rehabilitation with more dropouts, lower levels of physical activity, and poorer improvements in health status compared with men, with higher inflammatory levels at 1-year from index presentation. Future strategies should focus on primary and secondary prevention, adherence, and post-AMI health-related quality of life. This review discusses the current evidence in the epidemiology, diagnosis, and treatment of AMI in young women.

Association Between Depressive Symptoms and Exercise Capacity in Patients With Heart Disease: A META-ANALYSIS

PURPOSE

Depression and reduced exercise capacity are risk factors for poor prognosis in patients with heart disease, but the relationship between the 2 is unclear. We assessed the relationship between depressive symptoms and exercise capacity in patients with heart disease.

METHODS

PubMed, Cochrane Library, Google Scholar, and ProQuest databases were browsed for English-language studies published from January 2000 to September 2013. Studies including adult patients with coronary artery disease, heart failure, congenital heart disease, and implantable cardioverter defibrillator, reporting correlation between a depression scale and exercise capacity ((Equation is included in full-text article.)O2peak, peak watts, estimated metabolic equivalents, and incremental shuttle walk test distance), as well as studies from which such a correlation could be calculated and provided by the authors, were included. Correlation coefficients (CCs) were converted to Fischer z values, and the analysis was performed using a random-effects model. Then, summary effects and 95% CIs were converted back to CCs.

RESULTS

Fifty-nine studies (25 733 participants) were included. Depressive symptoms were inversely correlated to exercise capacity (CC = -0.15; 95% CI, -0.17 to -0.12). Heterogeneity was significant (I = 64%; P < .001). There was no evidence of publication bias (Fail-safe N = 4681; Egger test: P = .06; Kendall test: P = .29).

CONCLUSIONS

Patients with heart disease and elevated depressive symptoms may tend to have reduced exercise capacity, and vice versa. This finding has clinical and prognostic implications. It also encourages research on the effects of improving depression on exercise capacity, and vice versa. The effects of potential moderators need to be explored.

Effect of Motivational Interviewing on depression scale scores of adolescents with obesity and overweight

The aim of this study was to compare the effect of motivational interview (MI) with conventional care on the depression scale scores of adolescents with obesity/overweight. It was a controlled cluster randomized trial with parallel design, including two groups: intervention group [Motivational Interview Group (MIG)], control group [Conventional Intervention Group (CIG)].

INTERVENTION

three face-to-face 30min' interviews three months apart (only MIG interviews were based on MI principles).

OUTCOMES

change in Children Depression Inventory (CDI) scores. We used a mixed repeated-measures ANOVAs analysis to assess the group vs time interaction. Effect size was calculated for ANOVA with difference of means of the total score (DOMTS). CDI scores were compared by a paired t-test. Eighty-three (84%) adolescents finished the intervention. There was a significant time vs group interaction both groups. While in the CIG scores significantly increased, in the MIG the scores significantly decreased. The DOMTS was significantly different between the two groups. We concluded that MI showed a positive effect on depression scale scores over time relatively to conventional intervention.

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).

Exercise as a treatment for depression: A meta-analysis

BACKGROUND

This meta-analysis of randomized controlled trials (RCTs) examines the efficacy of physical exercise as treatment for unipolar depression, both as an independent intervention and as an adjunct intervention to antidepressant medication.

METHODS

We searched PsycINFO, EMBASE, MEDLINE, CENTRAL, and Sports Discus for articles published until November 2014. Effect sizes were computed with random effects models. The main outcome was reduction in depressive symptoms or remission.

RESULTS

A total of 23 RCTs and 977 participants were included. Physical exercise had a moderate to large significant effect on depression compared to control conditions (g=-0.68), but the effect was small and not significant at follow-up (g=-0.22). Exercise compared to no intervention yielded a large and significant effect size (g=-1.24), and exercise had a moderate and significant effect compared to usual care (g=-0.48). The effects of exercise when compared to psychological treatments or antidepressant medication were small and not significant (g=-0.22 and g=-0.08, respectively). Exercise as an adjunct to antidepressant medication yielded a moderate effect (g=-0.50) that trended toward significance.

LIMITATIONS

Use of the arms with the largest clinical effect instead of largest dose may have overestimated the effect of exercise.

CONCLUSIONS

Physical exercise is an effective intervention for depression. It also could be a viable adjunct treatment in combination with antidepressants.

The Relationship between Allostatic Load and Psychosocial Characteristics among Women Veterans

BACKGROUND

Allostatic load (AL) is a novel perspective for examining the damaging effects of stress on health and disease. Women veterans represent an understudied yet vulnerable subgroup of women with increased reports of traumatic stressors across their lifespan. AL has not been examined in this group. This study hypothesized that reports of sexual assault in childhood, civilian life, or in the military by women veterans was associated with AL and selected psychosocial measures. We also hypothesized that AL scores are positively associated with psychosocial characteristics.

METHODS

Using a cross-sectional design, psychosocial and physiological data were obtained from women veterans (n = 81; 24-70 years old).

FINDINGS

The AL score was 3.03 ± 2.36 and positively associated with age (p = .001). There was a trend for higher pain scores for women with an AL score of 2 or greater compared with those with an AL score of less than 2. There were significant differences in the Somatic Subscale of the Center for Epidemiological Depression Scale among the sexual assault categories with increasing scores among women reporting sexual assault in childhood, military, and civilian life (p = .049). The scores of the Profile of Mood States Depression/Dejection Subscale (p = .015), the Post-Traumatic Checklist- Military (p = .002), and the Pain Outcome Questionnaire (p = .001) were associated with sexual assault categories in a dose-response fashion.

CONCLUSIONS

AL was associated positively with age, and sexual assault categories were associated with increased somatization, depressed mood, posttraumatic symptoms and pain. Assessing both AL and sexual trauma are critical for preventing and managing the subsequent negative health consequences among women veterans.

Efficacy of psychosocial interventions on psychological outcomes among people with cardiovascular diseases: a systematic review and meta-analysis

OBJECTIVES

This systematic review aimed to examine empirical evidence concerning the efficacy of psychosocial interventions in ameliorating the psychosocial problems of people with cardiovascular diseases (CVDs).

METHODS

A comprehensive literature search was undertaken to identify both published and non-published English randomised controlled trials (RCTs) from 2000 to 2015. Two reviewers independently screened, assessed risks for bias, and extracted data. Comprehensive meta-analysis software was used to analyse the extracted data. Hedges's g effect size was used to determine the effects of psychosocial interventions.

RESULTS

Thirty studies were included in the review but only 18 studies reported significant short-term effects of psychosocial interventions in CVD patients. Most studies did not report long-term effects. Average effect sizes for stress, anxiety, depression, and combined depression/anxiety were 0.34, 1.04, 0.42 and 0.67 respectively at post-tests. Those numbers became 0.09, 0.65, 0.22 and 0.09 at follow-up assessments. Psychosocial programmes with psychoeducation and stress management helped reduce patients' stress and anxiety levels. Programmes including psychotherapy, counselling, mindfulness-based intervention (MBI), and stress management helped mitigate depression and anxiety.

CONCLUSIONS

The findings support the efficacy of some psychosocial interventions in people with CVDs.

PRACTICE IMPLICATIONS

Healthcare providers should monitor patients' psychological problems and may integrate psychosocial interventions as part of treatment plans.

Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of mortality in American women. Since 1984, the annual cardiovascular disease mortality rate has remained greater for women than men; however, over the last decade, there have been marked reductions in cardiovascular disease mortality in women. The dramatic decline in mortality rates for women is attributed partly to an increase in awareness, a greater focus on women and cardiovascular disease risk, and the increased application of evidence-based treatments for established coronary heart disease. This is the first scientific statement from the American Heart Association on acute myocardial infarction in women. Sex-specific differences exist in the presentation, pathophysiological mechanisms, and outcomes in patients with acute myocardial infarction. This statement provides a comprehensive review of the current evidence of the clinical presentation, pathophysiology, treatment, and outcomes of women with acute myocardial infarction.

Biopsychosocial health disparities among young women enrolled in cardiac rehabilitation

PURPOSE

Our aim was to compare the biopsychosocial characteristics of young women with those of older women who were enrolled in cardiac rehabilitation (CR). The baseline characteristics of women who prematurely terminated CR participation were also explored.

METHODS

Baseline physiological and psychosocial indices of women ≤ 55 years compared with older women eligible for CR were evaluated 1 week before enrolling in either a traditional CR or a gender-specific, motivationally enhanced CR.

RESULTS

A greater proportion of young women (n = 65) compared with their older counterparts (n = 187) were diagnosed with acute myocardial infarction during their index hospitalization. They demonstrated lower high-density lipoprotein cholesterol, higher total cholesterol/high-density lipoprotein cholesterol ratios, and greater body weight compared with older women and were more likely to be active smokers. Young women compared with older women reported significantly worse health perceptions, quality of life, optimism, hope, social support, and stress and significantly more symptoms of depression and anxiety. Women who prematurely terminated CR participation were younger, more obese, with worse quality of life, and greater symptoms of depression and anxiety compared with women completing CR.

CONCLUSIONS

Notable differences in physiological and psychosocial profiles of young women compared with older women enrolled in CR were evident, placing them at high risk for nonadherence to secondary prevention interventions as well as increased risk for disease progression and subsequent cardiac adverse events. Continued existence of these health differentials represents an important public health problem and warrants further research to address these age-related and sex-specific health disparities among women with coronary heart disease.

Effectiveness of motivational interviewing on lifestyle modification and health outcomes of clients at risk or diagnosed with cardiovascular diseases: A systematic review

BACKGROUND AND OBJECTIVE

Clinically, there is an increasing trend in using motivational interviewing as a counseling method to help clients with cardiovascular diseases to modify their unhealthy lifestyle in order to decrease the risk of disease occurrence. As motivational interviewing has gained increased attention, research has been conducted to examine its effectiveness. This review attempts to identify the best available evidence related to the effectiveness of motivational interviewing on lifestyle modification, physiological and psychological outcomes for clients at risk of developing or with established cardiovascular diseases.

DESIGN

Systematic review of studies incorporating motivational interviewing in modifying lifestyles, improving physiological and psychological outcomes for clients at risk of or diagnosed with cardiovascular diseases.

DATA SOURCES

Major English and Chinese electronic databases were searched to identify citations that reported the effectiveness of motivational interviewing. The searched databases included MEDLINE, British Nursing Index, CINAHL Plus, PsycINFO, SCOPUS, CJN, CBM, HyRead, WanFang Data, Digital Dissertation Consortium, and so on.

REVIEW METHOD

Two reviewers independently assessed the relevance of citations based on the inclusion criteria. Full texts of potential citations were retrieved for more detailed review. Critical appraisal was conducted by using the standardized critical appraisal checklist for randomized and quasi-randomized controlled studies from the Joanna Briggs Institute - Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStaRI).

RESULTS

After eligibility screening, 14 articles describing 9 studies satisfied the inclusion criteria and were included in the analysis. Only certain outcomes in certain studies were pooled for meta-analysis because of the large variability of the studies included, other findings were presented in narrative form. For lifestyle modification, the review showed that motivational interviewing could be more effective than usual care on altering smoking habits. For physiological outcomes, the review showed that motivational interviewing positively improved client's systolic and diastolic blood pressures but the result was not significant. For psychological outcomes, the review showed that motivational interviewing might have favorable effect on improving clients' depression. For other outcomes, the review showed that motivational interviewing did not differ from usual care or usual care was even more effective.

CONCLUSIONS

The review showed that motivational interviewing might have favorable effects on changing clients' smoking habits, depression, and three SF-36 domains. For the other outcomes, most of the results were inconclusive. Further studies should be performed to identify the optimal format and frequency of motivational interviewing. Primary research on the effectiveness of motivational interviewing on increasing clients' motivation and their actual changes in healthy behavior is also recommended.

Gender differences in illness behavior after cardiac surgery

PURPOSE

Differences in the ways male and female patients confront their illness after cardiac surgery may contribute to previously observed gender differences in the outcomes of cardiac rehabilitation. The aim of this cross-sectional study was to verify whether there are gender-related differences in illness behavior (IB) soon after cardiac surgery and before entering cardiac rehabilitation.

METHODS

Patients (N = 1323) completed the IB Questionnaire and Hospital Anxiety and Depression Scale (HADS) 9 ± 5 (mean ± SD) days after cardiac surgery. The scores were tested for gender differences in score distributions (Mann-Whitney U test) and in prevalence of clinically relevant scores (the Pearson χ² test). Multivariate regression analyses were made with IB Questionnaire and HADS scores as independent variables, and gender, age, education, marital status, and type of surgery as predictors.

RESULTS

Denial was significantly (P < .01) prevalent among the men (3.6 ± 1.4) versus women (3.2 ± 1.6), whereas disease conviction (men = 2.1 ± 1.5, women = 2.5 ± 1.6), dysphoria (men = 1.5 ± 1.5, women = 2.0 ± 1.6), anxiety (men = 6.0 ± 3.6, women = 6.9 ± 3.9), and depression (men = 5.3 ± 3.8, women = 6.5 ± 4.0) were significantly more prevalent among women. The prevalences of clinically relevant scores for disease conviction, anxiety, and depression were also significantly higher in women. Multivariate analysis showed that gender predicted these scores even after the removal of confounders.

CONCLUSIONS

Gender differences exist in denial, disease conviction, and dysphoria, probably depending on the culturally assigned roles of men and women. As these aspects of IB may compromise treatment compliance and the quality of life, the efficacy of cardiac rehabilitation programs might be improved taking into account the different prevalences in men and women.

Improvements in heart rate recovery among women after cardiac rehabilitation completion

BACKGROUND

Heart rate recovery (HRR) after exercise cessation is thought to reflect the rate of reestablishment of parasympathetic tone. Relatively little research has focused on improved HRR in women after completing cardiac rehabilitation (CR) exercise training.

OBJECTIVE

We examined the influence of exercise training on HRR in women completing a traditional CR program and in women completing a CR program tailored for women.

METHODS

A 2-group randomized clinical trial compared HRR between 99 women completing a traditional 12-week CR program and 137 women completing a tailored CR program. Immediately upon completion of a symptom-limited graded exercise test, HRR was measured at 1 through 6 minutes.

RESULTS

Compared with baseline, improvement in 1-minute HRR (HRR1) was similar (P = 0.777) between the tailored (mean [SD], 17.5 [11] to 19.1 [12]) and the traditional CR program (15.7 [9.0] to 16.9 [9.5]). The amount of change in the 2-minute HRR (HRR2) for the tailored (30 [13] to 32.8 [14.6]) and traditional programs (28.3 [12.8] to 31.2 [13.7]) also was not different (P = 0.391). Similar results were observed for HRR at 3 through 6 minutes. Given these comparable improvements of the 2 programs, in the full cohort, the factors independently predictive of post-CR HRR1, in rank order, were baseline HRR1 (part correlation, 0.35; P < 0.001); peak exercise capacity, estimated as metabolic equivalents (METs; 0.24, P < 0.001); anxiety (-0.17, P = 0.001); and age (-0.13, P = 0.016). The factors independently associated with post-CR HRR2 were baseline HRR2 (0.44, P < 0.001), peak METs (0.21, P < 0.001), and insulin use (-0.10, P = 0.041).

CONCLUSIONS

One to 6 minutes after exercise cessation, HRR was significantly improved among the women completing both CR programs. The modifiable factors positively associated with HRR1 included peak METs and lower anxiety, whereas HRR2 was associated with insulin administration and peak METs. Additional research on HRR after exercise training in women is warranted.

[Gender-specific aspects of coronary heart disease]

The total number of deaths from cardiovascular diseases (CVD) is greater for women than for men, although the mean age at manifestation of CVD is about 10 years older. However, the annual number of cases treated for CVD in acute hospital settings in men exceeds that of women by 50 %. Remarkable gender differences exist in terms of morphological and physiological conditions (e.g. mean coronary vessel diameter; ability to adapt to protective exercise-induced myocardial hypertrophy), as well as of the frequency and clinical significance of somatic risk factors (e.g. smoking). Female body weight increases after menopause and the body shape assumes a more android fat distribution. Women report higher levels of unspecific and affective symptoms. They suffer more from anxiety and depression than men; however, the secondary impact on CVD onset may be less pronounced. The post-acute CVD course is more complicated in women, mainly because they are older and suffer more from multi-morbidity. Whilst male CVD patients aim for a rapid recovery, physical fitness and an increased life expectancy, female patients seek relief from everyday challenges, the maintenance of their independence and emotional support.

Physiological and exercise capacity improvements in women completing cardiac rehabilitation

PURPOSE

The objective of this study was to examine the improvements in physiological outcomes, including exercise capacity, in women completing a 12-week gender-specific (tailored) compared with a traditional cardiac rehabilitation (CR) program.

METHODS

A 2-group randomized clinical trial compared symptom limited graded exercise test (SL-GXT), lipid, and anthropometric parameters among 99 women completing a traditional 12-week CR program with 137 women completing a tailored CR program.

RESULTS

Compared with baseline, improvement in estimated peak metabolic equivalents (METs) was similar (P = .159) between the tailored (6.0 ± 2.7-7.6 ± 2.8) and the traditional CR programs (5.6 ± 2.3-7.1 ± 2.8). The amount of change in SL-GXT, anthropometric parameters, lipid profiles, and peak treadmill time from baseline to post-CR were also similar between the 2 groups. Given comparable improvements of the 2 CR programs, in the full cohort, factors independently associated with post-CR METs, in rank order, included baseline METs (part correlation = 0.44, P < .001), perceived physical functioning (0.24, P < .001), waist circumference (-0.10, P = .006), and age (-0.11, P = .004). Factors independently associated with post-CR treadmill time included baseline treadmill time (part correlation = 0.42, P < .001), perceived physical functioning (0.30, P < .001), waist circumference (-0.12, P = .002), and age (-0.10, P 5.006).

CONCLUSIONS

Exercise capacity was significantly improved among women completing both CR programs. In the context of CR, modifiable factors positively associated with post-CR exercise capacity included reduced waist circumference and improved physical functioning. Future research on strategies for reducing abdominal obesity and improving perceived physical functioning and exercise capacity among women attending CR is warranted.

A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease

OBJECTIVE

To quantify the efficacy of mental health (antidepressants & psychotherapies) and cardiac rehabilitation treatments for improving secondary event risk and depression among patients with coronary heart disease (CHD).

METHODS

Using meta-analytic methods, we evaluated mental health and cardiac rehabilitation therapies for a) reducing secondary events and 2) improving depression severity in patients with CHD. Key word searches of PubMed and Psychlit databases and previous reviews identified relevant trials.

RESULTS

Eighteen mental health trials evaluated secondary events and 22 trials evaluated depression reduction. Cardiac rehabilitation trials for the same categories numbered 17 and 13, respectively. Mental health treatments did not reduce total mortality (absolute risk reduction [ARR] = -0.001, confidence interval [95% CI] = -0.016 to 0.015; number needed to treat [NNT] = ∞), showed moderate efficacy for reducing CHD events (ARR = 0.029, 95% CI = 0.007 to 0.051; NNT = 34), and a medium effect size for improving depression (Cohen d = 0.297). Cardiac rehabilitation showed similar efficacy for treating depression (d = 0.23) and reducing CHD events (ARR = 0.017, 95% CI = 0.007 to 0.026; NNT = 59) and reduced total mortality (ARR = 0.016, 95% CI = 0.005 to 0.027; NNT = 63).

CONCLUSIONS

Among patients with CHD, mental health treatments and cardiac rehabilitation may each reduce depression and CHD events, whereas cardiac rehabilitation is superior for reducing total mortality risk. The results support a continued role for mental health treatments and a larger role for mental health professionals in cardiac rehabilitation.

Cardiac rehabilitation may not provided a quality of life benefit in coronary artery disease patients

Background

Improvements in patient-reported health-related quality of life (HRQoL) are important goals of cardiac rehabilitation (CR). In patients undergoing coronary angiography for angina and with documented coronary artery disease (CAD), the present study compared HRQoL over 6 months in CR participants and non-participants. Clinical predictors of CR participants were also assessed.

Methods

A total of 221 consecutive patients undergoing angiography for angina with documented CAD and who were eligible for a CR program were recruited. CR participants were enrolled in a six-week Phase II outpatient CR course (31%, n = 68) within 2 months following angiography and the non-participants were included as a control. At baseline (angiography), one and six months post angiography, clinical and HRQoL data were obtained including the Short Form-36 (SF-36) and the Seattle Angina Questionnaire (SAQ). The response rate for the HRQoL assessment was 68% (n = 150). Cross sectional comparisons were age-adjusted and performed using logistic or linear regression as appropriate. Longitudinal changes in HRQoL were assessed using least squares regression. Finally, a multiple logistic regression was fitted with CR participant as the final outcome.

Results

At angiography, the CR non-participants were older, and age-adjusted analyses revealed poorer physical (angina limitation: 54 ± 25 versus 64 ± 22, p <0.05) and mental HRQoL (significant psycho-social distress: 62%, n = 95 versus 47%, n = 32, p <0.05) compared to the CR participants. In addition, the CR participants were more likely to have undergone angiography for myocardial infarction (OR = 2.8, 95% CI 1.5-5.3, p = 0.001). By six months, all patients showed an improvement in HRQoL indices, however the rate of improvement did not differ between the controls and CR participants.

Conclusion

Following angiography, CAD patients reported improvements in both generic and disease-specific HRQoL, however CR participation did not influence this outcome. This may be explained by biases in CR enrollment, whereby acute patients, who may be less limited in HRQoL compared to stable, chronic patients, are targeted for CR participation. Further investigation is required so CR programs maximize the quality of life benefits to all potential CR patients.

Meta-analysis of the effect of cardiac rehabilitation interventions on depression outcomes in adults 64 years of age and older

Heart disease is a major cause of hospitalization and is associated with greater impairment than arthritis, diabetes mellitus, or lung disease. Depression is prevalent and a serious co-morbidity in heart disease with negative consequences including higher levels of chronic physical illness, decreased psychological well-being, and increased health care costs. The objective of the study was to examine with meta-analysis the impact of community-based cardiac rehabilitation (CR) treatment on depression outcomes in older adults. Randomized controlled trials comparing patients (≥64 years old) receiving CR to cardiac controls were considered. Meta-analyses were based on 18 studies that met inclusion criteria, comprising 1,926 treatment participants and 1,901 controls. Effect sizes (ESs) ranged from -0.39 (in favor of control group) to 1.09 (in favor of treatment group). Mean weighted ES was 0.28, and 11 studies showed positive ESs. Meta-analysis suggests that most CR programs delivered in the home can significantly mitigate depression symptoms. Tailored interventions combined with psychosocial interventions are likely to be more effective in decreasing depression in older adults with heart disease than usual care.

Eliminating untimely deaths of women from heart disease: highlights from the Minnesota Women's Heart Summit

Despite national campaigns to increase awareness and reduce cardiovascular disease (CVD) mortality in women, CVD remains their leading cause of death, annually killing more women than men. Although some progress has been made in our understanding and treatment of CVD in women, the causes, extent, and demographic trends of observed sex differences and disparities remain uncertain, and the growing burden of CVD and its risk factors among younger women is concerning. The Minnesota Women's Heart Summit was convened to chart a course to eliminate premature deaths of women from heart disease. The multidisciplinary summit was hosted by the Minneapolis Heart Institute, Minneapolis Heart Institute Foundation, University of Minnesota, and Mayo Clinic. Presentations highlighted sex-based differences in symptoms, treatment, and outcomes, and panel experts provided commentary. Invited faculty and summit participants worked in small-group sessions to identify strategies to dissolve barriers, improve primary and secondary prevention, and enhance women's care and outcomes. This report summarizes strategies identified during the conference to serve as springboards for more substantive future initiatives. These include, for example, standardized data collection and use of existing data sets to inform perspectives on sex-related cardiovascular issues, mandatory reporting of sex-specific data, and increased attention to underserved/high-risk women. Participants acknowledged that implementing these ideas would be challenging and recommended key priorities/next action steps such as providing services close to "point-of-life" rather than "point-of-care" and creation of policies and regulations so that resources and environmental modifications encouraging healthier lifestyle choices are promoted. Additional research is needed to improve identification, treatment, and health behaviors and to address continued lack of awareness, symptom recognition delays, barriers to care, and outcome disparities-especially in diverse populations.

Psychological risk factors and cardiovascular disease: is it all in your head?

Psychological stress has been shown to be associated with cardiovascular disease. Over the past few decades, there has been an increasing interest in this relationship, leading to a growing pool of clinical and epidemiological data on the subject. Psychological stress has multiple etiologies, which include behavioral causes, acute events or stressors, and/or chronic stress. Cardiac rehabilitation and exercise therapy have been shown to provide protection in primary and secondary coronary heart disease prevention, as well as improve overall morbidity and mortality. In this article, we review the available data regarding the association between psychological stress and cardiovascular disease, as well as the impact of cardiac rehabilitation and exercise therapy on psychological stress-related cardiovascular events.