Psychosocial management in cardiac rehabilitation: Current practices, recommendations, and opportunities

Temporal Trends in Cardiac Rehabilitation Participation and Its Core Components: A Nationwide Cohort Study From the Netherlands

PURPOSE

Patient- and disease-specific data on cardiac rehabilitation (CR) participation and changes over time are limited. The objective of this study was to describe time trends in CR participation between 2013 and 2019 and provides insights into the utilization of CR components.

METHODS

Patients with cardiovascular disease (CVD) with an indication for CR were enrolled between 2013 and 2019. Dutch health insurance claims data were used to identify CR participation and its components.

RESULTS

In total, 106 212 patients with CVD were included of which 37% participated in CR. Participation significantly increased from 28% in 2013 to 41% in 2016 but remained unchanged thereafter. Participation was highest in the youngest age groups (<50 yrs 52%; 50-65 yrs 50%), men (48%), patients with ST-segment elevation myocardial infarction (73%), non-ST-segment elevation myocardial infarction (59%), and coronary artery bypass grafting (82%). In contrast, it was the lowest in the oldest age group (≥85 yrs 8%), women (30%), and in patients with heart failure (11%). Most participants in CR received referral plus an admission session (97%) and exercise training (82%), whereas complementary services related to dietary (14%) and mental health counseling (10%) had a low utilization.

CONCLUSIONS

CR participation rates increased to 41% in 2016 but remained unchanged thereafter. Participation modulators included age, sex, CVD diagnosis, and undergoing a cardiothoracic procedure. Education and exercise sessions were frequently adopted, but dietary and mental health counseling had a low utilization rate. These findings suggest the need for reinvigorated referral and novel enrollment strategies in specific CVD subgroups to further promote CR participation and its associated underutilized adjunctive services.

Patients' Perceptions of Hybrid and Virtual-Only Care Models During the Cardiac Rehabilitation Patient Journey: A Qualitative Study

BACKGROUND

The COVID-19 pandemic initially led to discontinuation of the "traditional" center-based cardiac rehabilitation (CR) model. Virtual models emerged as an opportunity to deliver care, with many programs continuing to offer these models.

OBJECTIVE

The aim of this study was to explore patients' perceptions of virtual models of either hybrid (combining center-based and virtual) or virtual-only CR since the pandemic.

METHODS

Men and women who chose to participate in hybrid or virtual CR models between January 2022 and January 2023 were invited to attend 1 of 8 focus group sessions. Focus groups were conducted online until thematic saturation was reached. Transcripts were analyzed using thematic analysis.

RESULTS

Twenty-three patients (48% female; 83% attending hybrid CR) participated in the study. Analysis revealed 12 overarching themes associated with the CR patient journey: pre-CR, namely, (1) importance of endorsement from healthcare providers and (2) need for education/communication while waiting for program initiation; during CR, namely, (3) preference for class composition/structure, (4) need to enhance peer support in the virtual environment, (5) convenience and concerns with virtual sessions, (6) necessity of on-site sessions, (7) safety of the exercise prescription, (8) requirement/obligation for allied health offerings, (9) satisfaction with virtual education, and (10) use of technology to facilitate CR participation; and post-CR, namely, (11) acknowledgment of program completion and (12) need for support/education after program graduation.

CONCLUSIONS

Patients require ongoing support from time of referral to beyond CR program completion. Physical, psychosocial, nutritional, and educational supports are needed. Perceptions expressed by patients related to the program model are modifiable, and strategies to address these perceptions should be explored.

Do the American guideline-based leisure time physical activity levels for civilians benefit the mental health of military personnel?

Backgrounds

This study aimed to clarify the association of American guideline-based leisure time physical activity (PA) level with mental health in 4,080 military personnel in Taiwan.

Methods

The moderate intensity PA level was assessed according to the total running time per week (wk) reported in a self-administered questionnaire over the previous 6  months and was categorized into PA level <150, 150-299, and ≥300  min/wk. Mental stress was assessed by the Brief Symptom Rating Scale (BSRS)-5 for which ≥15 points were classified as great mental stress. Suicide ideation (SI) was graded as 1 for mild, 2 for moderate, and 3 or 4 for severe. Multivariable logistic regression analysis was employed to determine the association between PA and mental health while adjusting for demographics, smoking, alcohol intake, betel nut chewing, and obesity.

Results

As compared to participants with a PA level of <150  min/wk., those with PA levels 150-299  min/wk. and ≥  300  min/wk. had a lower possibility of SI ≥1 [odds ratios (ORs) and 95% confidence intervals (CIs): 0.58 (0.40-0.83) and 0.23 (0.14-0.36), respectively] and SI ≥1 and/or BSRS-5 ≥  15 [ORs: 0.55 (0.39-0.79) and 0.21 (0.13-0.34), respectively]. The possibilities were more significantly lower for SI ≥2 [ORs: 0.37 (0.20-0.68) and 0.10 (0.04-0.26), respectively] and SI ≥2 and/or BSRS-5 ≥  15 [ORs: 0.35 (0.20-0.62) and 0.10 (0.04-0.25), respectively].

Conclusion

Our findings indicate that participating in moderate-intensity leisure time PA level for ≥150  min/wk. may have a positive effect on mental health among military personnel. The impact appears to be even more significant when engaging in a higher PA level of ≥300  min/wk.

Association of Depression and Cardiovascular Disease

BACKGROUND

Cardiovascular disease remains the leading worldwide cause of mortality. There has been increased awareness of the impact of psychological health on cardiovascular disease. In particular, major depression has been linked to increased all-cause mortality, development of cardiovascular disease, and worse outcomes in those with existing cardiovascular disease.

METHODS

We conducted a meta-analysis assessing the incidence of cardiovascular disease and cardiovascular disease outcomes among those with major depressive disorder.

RESULTS

Among 26 studies of 1,957,621 individuals, depression was associated with increased risk of incident stroke (hazard ratio [HR] 1.13; 95% confidence interval [CI], 1.00-1.28), myocardial infarction (HR 1.28; 95% CI, 1.14-1.45), congestive heart failure (HR 1.04; 95% CI, 1.00-1.09), or any cardiovascular disease (HR 1.16; 95% CI, 1.04-1.30). Depression was associated with increased risk of all-cause mortality (HR 1.43; 95% CI, 1.27-1.60), cardiovascular disease mortality (HR 1.44; 95% CI, 1.27-1.63), and congestive heart failure mortality (HR 3.20; 95% CI, 1.29-7.94).

CONCLUSION

Depression has a significant negative impact on development of cardiovascular disease and on cardiovascular disease outcomes. Further efforts to understand and mitigate these impacts are prudent.

Effectiveness of a short-term multimodal prehabilitation program in adult patients awaiting selective cardiac surgery: study protocol for an open-label, pilot, randomized controlled trial

Background

Prehabilitation has been demonstrated to positively impact postoperative recovery in patients undergoing selective cardiac surgery. However, the optimal modules included in prehabilitation programs are yet to be fully explored, as existing studies have primarily focused on exercise. This study will explore the effectiveness of a three-arm prehabilitation program among adult patients awaiting selective cardiac surgery.

Methods and analysis

A single-center, parallel-group randomized controlled trial will be conducted at the Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU). A total of 152 adult patients scheduled for elective cardiac surgery (coronary artery bypass grafting or valvular surgery) will be recruited from a tertiary teaching hospital. The patients will be randomly assigned to either the control group or the prehabilitation group. Patients assigned to the control group will receive standard care, which includes patient education and counseling as well as personal guidance on exercise, breathing, and coughing. Patients in the intervention group will be provided a multimodal prehabilitation program, including nutrition guidance, a diet journal, mindfulness training, and exercise guidance. The interventions will begin with home-based training and continue after hospital admission and before surgery. The primary outcome will be the perioperative 6-minute walk distance (6 MWD). The secondary outcomes will include preoperative readiness, postoperative recovery, and patient experience with the program.

Discussion

The purpose of the study is to examine whether a short-term multimodal prehabilitation program will be associated with improved preoperative readiness and postoperative outcomes. The findings of this study will provide evidence to support the development of a perioperative program aimed at enhancing patient recovery.

Clinical Trial Registration

www.ClinicalTrials.gov; identifier: NCT05503004.

Mindfulness-Based Interventions for Patients with Cardiovascular Disease: A Focused Review for Practicing Clinicians

PURPOSE OF REVIEW

With growing scientific and public interest in the health benefits of mindfulness, clinicians increasingly face questions and solicitations for advice from patients about the efficacy of mindfulness-based interventions (MBIs) for cardiovascular disease (CVD). In this clinician-focused review, we aim to revisit empirical studies on MBIs for CVD with the purpose of informing clinicians' decisions on how to provide recommendations consistent with updated scientific findings to patients interested in MBIs.

RECENT FINDINGS

We start by defining MBIs and identifying the possible physiological, psychological, behavioral, and cognitive mechanisms underlying the potentially positive effects of MBIs for CVD. Potential mechanisms include the reduction of sympathetic nervous system activity, improved vagal control, and biological markers (physiological); psychological distress and cardiovascular health behaviors (psychological and behavioral); and executive function, memory, and attention (cognitive). Then, we summarize the extant evidence to identify gaps and limitations in MBI research for the purpose of informing future directions for cardiovascular and behavioral medicine researchers. We conclude with practical recommendations for clinicians communicating with patients with CVD who are interested in MBIs.

Psychosocial services provided by licensed cardiac rehabilitation programs

Background

Professional health organizations recommend that outpatient cardiac rehabilitation programs include activities to optimize the physical, mental, and social well-being of patients. The study objectives were to describe among cardiac rehabilitation programs (1) mental health assessments performed; (2) psychosocial services offered; and (3) leadership's perception of barriers to psychosocial services offerings.

Methods

A cross-sectional survey of North Carolina licensed outpatient cardiac rehabilitation programs on their 2018 services was conducted. Descriptive statistics were used to summarize survey responses. Thematic analysis of free text questions related to barriers to programmatic establishment or expansion of psychosocial services was performed by two team members until consensus was reached.

Results

Sixty-eight programs (89%) responded to the survey. Forty-eight programs (70%) indicated offering psychosocial services; however, a majority (73%) of programs reported not directly billing for those services. At program enrollment, mental health was assessed in 94% of programs of which 92% repeated the assessment at discharge. Depression was assessed with the 9-item Patient Health Questionnaire by a majority (75%) of programs. Psychosocial services included individual counseling (59%), counseling referrals (49%), and educational classes (29%). Directors reported lack of internal resources (92%) and patient beliefs (45%) as the top barriers to including or expanding psychosocial services at their facilities.

Conclusions

Cardiac rehabilitation programs routinely assess mental health but lack the resources to establish or expand psychosocial services. Interventions aimed at improving patient education and reducing stigma of mental health are important public health opportunities.

The impact of Virtual Reality on Anxiety and Functional Capacity in Cardiac Rehabilitation: A Systematic Review and Meta-analysis

BACKGROUND

The overall utilization of cardiac rehabilitation (CR) is low despite its proven benefits in secondary prevention. Virtual reality (VR), a novel method of rehabilitation, may increase overall compliance. The purpose of this systematic review and meta-analysis is to synthesize evidence and report whether the addition of VR leads to an improvement in anxiety and functional capacity (FC) compared to standard CR.

METHODS

A comprehensive search strategy was used to search the online databases for the randomized controlled trials (RCTs) on VR-CR. Statistical analysis was performed using Stata SE version 17.0 (College Station, TX) and RevMan5.

RESULTS

A total of 747 study participants were part of 7 studies included in the meta-analysis. Three studies were part of the narrative synthesis. Anxiety showed significant improvement in VR-CR compared to standard CR (SMD -0.32, 95% CI -0.61, -0.03). There was no significant improvement in FC between VR-CR and the standard CR (SMD 0.077, 95% CI -1.24, 1.32).

CONCLUSION

VR-CR significantly improved CR-related anxiety compared to standard CR. However, no significant improvement in FC was found in VR-CR compared to the standard CR. Further studies are needed to assess the impact of non-immersive and immersive VR on FC.

Discrete choice experiment to investigate preferences for psychological intervention in cardiac rehabilitation

OBJECTIVE

Cardiac rehabilitation (CR) is offered to people who recently experienced a cardiac event, and often comprises of exercise, education and psychological care. This stated preference study aimed to investigate preferences for attributes of a psychological therapy intervention in CR.

METHODS

A discrete choice experiment (DCE) was conducted and recruited a general population sample and a trial sample. DCE attributes included the modality (group or individual), healthcare professional providing care, information provided prior to therapy, location and the cost to the National Health Service (NHS). Participants were asked to choose between two hypothetical designs of therapy, with a separate opt-out included. A mixed logit model was used to analyse preferences. Cost to the NHS was used to estimate willingness to pay (WTP) for aspects of the intervention design.

RESULTS

Three hundred and four participants completed the DCE (general public sample (n=262, mean age 47, 48% female) and trial sample (n=42, mean age 66, 45% female)). A preference for receiving psychological therapy was demonstrated by both samples (general population WTP £1081; 95% CI £957 to £1206). The general population appeared to favour individual therapy (WTP £213; 95% CI £160 to £266), delivered by a CR professional (WTP £48; 9% % CI £4 to £93) and with a lower cost (β=-0.002; p&lt;0.001). Participants preferred to avoid options where no information was received prior to starting therapy (WTP -£106; 95% CI -£153 to -£59). Results for the location attribute were variable and challenging to interpret.

CONCLUSIONS

The study demonstrates a preference for psychological therapy as part of a programme of CR, as participants were more likely to opt-in to therapy. Results indicate that some aspects of the delivery which may be important to participants can be tailored to design a psychological therapy. Preference heterogeneity is an issue which may prevent a 'one-size-fits-all' approach to psychological therapy in CR.

Impact of virtual reality on cardiac rehabilitation-related anxiety: a protocol for systematic review and meta-analysis

Introduction

Cardiac rehabilitation has proven beneficial in cardiovascular patients and is strongly recommended for secondary prevention after a coronary event. However, overall utilisation of cardiac rehabilitation is often low. The addition of novel methods of rehabilitation may increase overall compliance with cardiac rehabilitation. The use of virtual reality (VR) has been adopted in a variety of therapeutic ways such as physical rehabilitation in neurological diseases, rehabilitation for various psychiatric illnesses and postcancer rehabilitation in breast cancer survivors. In our meta-analysis, we wish to assess whether the addition of VR (fully immersive or non-immersive) leads to an improvement in anxiety and functional capacity compared with standard cardiac rehabilitation at any phase of the rehabilitation process.

Method and analysis

This systematic review and meta-analysis protocol was structured according to the published Preferred Reporting for Systematic Review and Meta-analysis—Protocol guidelines. We will devise a search strategy to use online databases to search for the randomised controlled trials. Inclusion criteria and exclusion criteria will be defined. The articles will be reviewed by two independent reviewers and any conflict will be adjudicated through discussion. The bias in the selected studies will be assessed using Cochrane risk-of-bias tool for randomised trials (RoB 2). The outcome of interest will be anxiety and functional capacity. Effect estimates will be reported as standardised mean difference with 95% CI. Fixed effect model will be used if I2<60%, otherwise random effect model will be used to estimate the effect size.

Ethics and dissemination

There will be no direct involvement of the patient or the public in the conception, design, data collection and analysis of this systematic review and meta-analysis. Results of this systematic review and meta-analysis will be disseminated via journal articles. In accordance with the guidelines, our systematic review protocol is prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 07 August 2022.

PROSPERO ID

CRD 42022342736.

Enhancing participation in cardiac rehabilitation: Focus on underserved populations

Participation in cardiac rehabilitation (CR) significantly decreases morbidity and mortality and improves quality of life following a wide variety of cardiac diagnoses and interventions. However, participation rates and adherence with CR are still suboptimal and certain populations, such as women, minorities, and those of lower socio-economic status, are particularly unlikely to engage in and complete CR. In this paper we review the current status of CR participation rates and interventions that have been used successfully to improve CR participation. In addition, we review populations known to be less likely to engage in CR, and interventions that have been used to improve participation specifically in these underrepresented populations. Finally, we will explore how CR programs may need to expand or change to serve a greater proportion of CR-eligible populations. The best studied interventions that have successfully increased CR participation include automated referral to CR and utilization of a CR liaison person to coordinate the sometimes awkward transition from inpatient status to outpatient CR participation. Furthermore, it appears likely that maximizing secondary prevention in these at-risk populations will require a combination of increasing attendance at traditional center-based CR programs among underrepresented populations, improving and expanding upon tele- or community-based programs, and alternative strategies for improving secondary prevention in those who do not participate in CR.