Psychological treatments in cardiac rehabilitation: review of rationales and outcomes

Efficacy of psychological interventions on clinical outcomes of coronary artery disease: Systematic review and meta-analysis

OBJECTIVES

Psychological factors influence clinical outcomes in patients with coronary artery disease (CAD). Therefore, psychological interventions (PIs) may have beneficial effects in these patients. We evaluated the efficacy of PIs based on cognitive-behavioral therapy (CBT) and positive psychology therapy (PPT) on clinical and laboratory outcomes in CAD.

METHODS

Randomized controlled trials evaluating CBT or PPT in CAD patients published until May 2020 were systematically reviewed and analyzed. Primary outcomes were all-cause mortality, cardiovascular mortality, any cardiovascular event, myocardial infarction (MI), stroke, coronary revascularization, angina, and readmission. Random effects meta-analyses using the inverse variance method were performed. Effects were expressed as risk ratios (RR) or standardized mean difference (SMD) with 95% confidence intervals (CIs).

RESULTS

Twenty-five trials were included (n = 8119); 22 evaluating the effects of multi-component CBT (n = 7909), and three PPT (n = 210). Thirteen RCTs were at high risk of bias due to limitations in randomization or blinding. Compared with control groups any cardiovascular event (RR 0.82; 0.70 to 0.97; 5 studies), MI (RR 0.72; 0.52 to 0.98; 9 studies), and angina duration and intensity (SMD -0.64; -0.98 to -0.30; 4 studies; and -0.64; -1.17 to -0.11; 2 trials) were significantly reduced with PIs at the end of follow-up. PIs had no effect on other primary outcomes, laboratory or anthropometrical results and presented a moderate to high heterogeneity.

CONCLUSIONS

CBT- and PPT-based PIs reduce the risk of cardiovascular events, MI and angina in patients with CAD. Future research should assess the individual role of CBT and PPT in CAD populations.

Effects of Supervised Cardiac Rehabilitation Programmes on Quality of Life among Myocardial Infarction Patients: A Systematic Review and Meta-Analysis

Coronary heart disease is the leading cause of death and disability worldwide. Traditionally, cardiac rehabilitation programmes are offered after cardiac events to aid recovery, improve quality of life, and reduce adverse events. The objective of this review was to assess the health-related quality of life, after a supervised cardiac rehabilitation programme, of patients who suffered a myocardial infarction. A systematic review was carried out in the CINAHL, Cochrane, LILACS, Medline, Scopus, and SciELO databases, according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. Randomised controlled trials were selected. Meta-analyses were performed for the Short Form Health Survey SF-36, Myocardial Infarction Dimensional Assessment Scale (MIDAS), MacNew Heart Disease-Health-Related Quality of Life (HRQL) questionnaire, and European Quality of Life-Visual Analogue Scale (EuroQol-VAS) with the software Cochrane RevMan Web. Ten articles were found covering a total of 3577 patients. In the meta-analysis, the effect size of the cardiac rehabilitation programme was statistically significant in the intervention group for physical activity, emotional reaction, and dependency dimensions of the MIDAS questionnaire. For the control group, the score improved for SF-36 physical functioning, and body pain dimensions. The mean difference between the control and intervention group was not significant for the remaining dimensions, and neither for the MacNew Heart Disease-HRQL and EuroQol-VAS questionnaires. Supervised cardiac rehabilitation programmes were effective in improving health-related quality of life, however, there was a potential variability in the interventions; therefore, the results should be interpreted with caution. This study supports the importance of providing care and evaluating interventions via the supervision of trained health professionals, and further randomised clinical trials are needed to analyse the positive changes in mental and physical health outcomes.

Efficacy of psychological interventions on psychological outcomes in coronary artery disease: systematic review and meta-analysis

BACKGROUND

The benefits of cognitive-behavioral treatment (CBT) and positive psychology therapy (PPT) in patients with cardiovascular disease are still not well defined. We assessed the efficacy of CBT and PPT on psychological outcomes in coronary artery disease (CAD) patients.

METHODS

Randomized controlled trials evaluating CBT or PPT in CAD patients published until May 2018 were systematically analyzed. Primary outcomes were depression, stress, anxiety, anger, happiness, and vital satisfaction. Random effects meta-analyses using the inverse variance method were performed. Effects were expressed as standardized mean difference (SMD) or mean differences (MD) with their 95% confidence intervals (CIs); risk of bias was assessed with the Cochrane tool.

RESULTS

Nineteen trials were included (n = 1956); sixteen evaluated CBT (n = 1732), and three PPT (n = 224). Compared with control groups, depressive symptoms (13 trials; SMD -0.80; 95% CI -1.33 to -0.26), and anxiety (11 trials; SMD -1.26; 95% CI -2.11 to -0.41) improved after the PI, and depression (6 trials; SMD -2.08; 95% CI -3.22 to -0.94), anxiety (5 trials; SMD -1.33; 95% CI -2.38 to -0.29), and stress (3 trials; SMD -3.72; 95% CI -5.91 to -1.52) improved at the end of follow-up. Vital satisfaction was significantly increased at follow-up (MD 1.30, 0.27, 2.33). Non-significant effects on secondary outcomes were found. Subgroup analyses were consistent with overall analyses.

CONCLUSION

CBT and PPT improve several psychological outcomes in CAD patients. Depression and anxiety improved immediately after the intervention while stress and vital satisfaction improve in the mid-term. Future research should assess the individual role of CBT and PPT in CAD populations.

Introduce a New Intervention Model Based on Islamic Lifestyle for Decreasing the Risk of Cardiovascular Disease in People at Risk: A Comparative Study

The main purpose of the present study was designing and assessing the common lifestyle and Islamic lifestyle interventions and comparison of them. Sample of the study was thirty-nine subjects participated in a healthy lifestyle program. The Islamic group were received the Islamic healthy lifestyle program. In comparison with common, in the Islamic group the CVD risk was significantly lower; the psychological well-being was increased significantly; the psychological distress was decreased significantly; and the spiritual well-being was increased significantly. The most powerful element of Islamic lifestyle was to strengthen the spirituality that can positively affect the life.

Psychoeducation: improving outcomes in bipolar disorder

Background

A relevant paradigm shift in the treatment of bipolar disorder started a few years ago; crucial findings on the usefulness of psychological interventions clearly support switching from an exclusively pharmacological therapeutic approach to a combined yet hierarchical model in which pharmacotherapy plays a central role, but psychological interventions may help cover the gap that exists between theoretical efficacy and “real world” effectiveness. Hereby we review the efficacy of several adjunctive psychotherapies in the maintenance treatment of bipolar patients.

Methods

A systematic review of the literature on the issue was performed, using MEDLINE and CURRENT CONTENTS databases. “Bipolar”, “Psychotherapy”, “Psychoeducation”, “Cognitive-behavioral” and “Relapse prevention” were entered as keywords.

Results

Psychological treatments specifically designed for relapse prevention in bipolar affective disorder are useful tools in conjunction with mood stabilizers. Most of the psychotherapy studies recently published report positive results on maintenance as an add-on treatment, and efficacy on the treatment of depressive episodes. Interestingly, several groups from all over the world reported similar positive results and reached very similar conclusions; almost every intervention tested contains important psychoeducative elements including both compliance enhancement and early identification of prodromal signs — stressing the importance of life-style regularity — and exploring patients' health beliefs and illness-awareness.

Conclusions

The usefulness of psychotherapy for improving treatment adherence and clinical outcome of bipolar patients is nowadays unquestionable, and future treatment guidelines should promote its regular use amongst clinicians. As clinicians, it is our major duty, to offer the best treatment available to our patients and this includes both evidence-based psychoeducation programs and newer pharmacological agents.

Psychophysical health of elderly inpatients in cardiac rehabilitation: a retrospective cohort study

BACKGROUND

Elderlies in cardiac rehabilitation show a particular frailty due to specific aging issues, thus specific professional psychophysical care is required.

AIM

This study aimed at evaluating the effect of a cardiac rehabilitation program enhanced with psychological support on the psychophysical health of elderly subjects aged ≥75. Moreover, the association of psychophysical conditions with the long-term post-discharge course of medical events was examined.

DESIGN

This retrospective cohort study was conducted on elderly patients aged ≥75 admitted from 2015 to 2019 to a cardiac rehabilitation program including psychological support.

SETTING

The cardiac ward and the psychology unit of a post-acute clinical rehabilitation Institute.

POPULATION

A total of 523 elderly inpatients (44% females), aged ≥75 years (mean 79.7±3.46 years), admitted to a cardiac rehabilitation ward due to heart disease.

METHODS

Psychological and functional variables such as depression, quality of life, and Barthel Index were measured at hospitalization and at discharge. The medical events after discharge such as emergency department accesses and rehospitalizations were registered.

RESULTS

Cardiac rehabilitation showed significant improvements both in elderlies' psychological and physical health. Higher depression levels predicted a worse post-discharge course. Patients who received psychological intervention accessed emergency department and were re-hospitalized significantly later than the others.

CONCLUSIONS

Cardiac comprehensive rehabilitation can significantly improve the psycho-physical health of elderly subjects aged ≥75 who benefit of psychological support. Psychological support can enhance the psychophysical health of great elder inpatients in cardiac rehabilitation.

CLINICAL REHABILITATION IMPACT

Given the associations with short and long-term outcomes, health professionals should take care of the psychological conditions of elderlies (e.g., depression) by integrating psychological interventions in cardiac rehabilitation in order to promote the elderlies' psychophysical conditions, quality of life, as well as more favorable medical outcomes.

Self-Reported Behavioural and Medical Changes in Women after Their First Myocardial Infarction: A 4-Year Comparison Between Participation and Non-Participation in a Cardiac Rehabilitation Programme

Background: Women's recovery following a myocardial infarction (MI) has not yet been studied in a thorough manner. Aim: Therefore, the aim of this study was to compare women's self-reported behavioural and medical changes, both in those women who voluntarily participated and those women who did not participate in a cardiac rehabilitation programme (CRP). Methods: A non-randomised comparative study design, including pre- (baseline) and post-tests (1 and 4 years after), was implemented in 18 hospitals in Sweden. Consecutively chosen women suffering their first MI ( N=240) completed a questionnaire regarding behavioural and medical factors. Results: At baseline, significant differences existed between the groups regarding time stress (increased in the CRP group) and hypertension (increased in the non-CRP group). The behavioural factors improved, irrespective of CRP participation or not, with the exception of time stress, which was consistently high in the CRP group both 1- and 4-years after the MI. Regarding the medical factors, the significant difference in hypertension disappeared after 1 year. Four years after the MI, the CRP group reported significantly less rehospitalisation and more interventive cardiology compared to the non-CRP group. Conclusion: The women benefited from CRP participation in relation to medical factors, but not at all in relation to behavioural factors. Accordingly, randomised clinical trials are necessary to perform in order to determine the effects of a long-term individual-based supportive CRP, performed by well-educated healthcare professionals.

Feasibility of a Cognitive-Behavioural Group Intervention for Men Experiencing Psychological Difficulties After Myocardial Infarction

Background: People experiencing psychological distress after a cardiac event may require special follow-up and targeted interventions in order to effectively decrease levels of distress. Aims: Men who were judged to be experiencing poor emotional adjustment post-myocardial infarction (MI) were invited to a cognitive behaviour therapy group. The current study examines the attendance at such a group and the consequent feasibility of such interventions. Method: The content of the group aimed to help men deal with the uncomfortable psychosocial issues that had arisen since having a MI. Results: Of the 26 men approached only 30% were interested in attending and only 11% actually completed the group. Two men who were committed to attending the group could not complete all the sessions, as heart bypass operations became available to them. Conclusion: Ways of involving men in interventions targeting psychological distress requires ongoing investigation.

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.

Psychosocial outcome in cardiovascular rehabilitation of peripheral artery disease and coronary artery disease patients

We investigated patients with a primary diagnosis of peripheral artery disease (n = 69) and coronary heart disease (CAD; n = 520) at baseline and on changes in psychosocial risk factors (depression, anxiety, quality of life, negative and positive affect) during a cardiovascular rehabilitation program. Patients completed psychosocial questionnaires at the beginning and at discharge of a 12-week rehabilitation program. Depression and anxiety were measured with the Hospital Anxiety and Depression Scale (HADS), positive and negative affect with the Global Mood Scale, and health-related quality of life with the SF-36 Health Survey. Patients with PAD showed improvements in anxiety (p < 0.001), negative affect (p < 0.001) and bodily pain (p < 0.001). Patients with CAD reported significant improvements in all measured dimensions (all p-values < 0.001).

Randomized controlled trial on the long-term efficacy of a multifaceted, interdisciplinary lifestyle intervention in reducing cardiovascular risk and improving lifestyle in patients at risk of cardiovascular disease

The objective of the study was to evaluate the efficacy of an interdisciplinary intervention known as Educoeur in reducing cardiovascular risk and improving health behaviors in people without evidence of cardiovascular disease and to compare the Educoeur program to interventions in a specialized clinic and in usual care family practice. In a parallel, randomized, controlled trial of 185 adults with at least two modifiable cardiovascular risk factors, patients were randomly assigned to either Educoeur, specialized clinic or usual care. Cardiovascular risk, biological and lifestyle measures were assessed at baseline and at 2 years. In Educoeur, measurements were also taken before and after the lifestyle group treatment program. In 12 weeks, patients in Educoeur significantly lowered their cardiovascular risk, weight, body mass index, waist circumference, systolic blood pressure, kilocalories intake and improved their VO2 Max and mental health. Changes remained significant at 2 years. Between group comparisons at 2 years demonstrated that Educoeur was significantly better in reducing cardiovascular risk than interventions in usual care. Together, these results highlight the importance of providing interdisciplinary programs that optimize cardiovascular risk reduction and promote active lifestyles in patients at risk of cardiovascular disease.

Treating anxiety in patients with coronary heart disease: a randomized controlled trial

BACKGROUND

Anxiety is frequent in patients with coronary heart disease (CHD) and influences the course of the disease, but no randomized controlled trial has investigated the effects of a psychotherapy intervention in CHD patients with elevated anxiety scores. The main aim of this study was to evaluate the effects of a 6-month psychotherapy intervention on anxiety in this group of patients.

METHODS

Fifty-two patients (61 ± 8.0 years, 14 female) with CHD and elevated levels of anxiety completed the study after randomization into a 6-month psychotherapy intervention or a control condition. Medically eligible patients were screened for anxiety with the Hospital Anxiety and Depression Scale (HADS) and were included if they had a score of 8 or higher. Anxiety scores were reevaluated at 6-month follow-up (after the treatment).

RESULTS

At 6-month follow-up significant reductions (intervention group: -2.0 ± 2.3; control group: -1.8 ± 2.8; p < 0.01) were found in both groups in the HADS anxiety scale but no significant differences between the groups were observed. Adjustment for baseline differences and disease severity did not change these results.

CONCLUSIONS

Our study showed that elevated anxiety scores were reduced over time but there was no statistically significant effect of the psychotherapy intervention in anxious patients with CHD. Changes in the design of the intervention and study might be useful to further investigate this topic in the future.

Clinical Psychology and Cardiovascular Disease: An Up-to-Date Clinical Practice Review for Assessment and Treatment of Anxiety and Depression

The aim of the present review is underline the association between cardiac diseases and anxiety and depression. In the first part of the article, there is a description of anxiety and depression from the definitions of DSM-IV TR. In the second part, the authors present the available tests and questionnaires to assess depression and anxiety in patients with cardiovascular disease. In the last part of the review different types of interventions are reported and compared; available interventions are pharmacological or psychological treatments.

Enhancing standard cardiac rehabilitation with stress management training: background, methods, and design for the enhanced study

PURPOSE

Enhancing Standard Cardiac Rehabilitation with Stress Management Training in Patients with Heart Disease (ENHANCED) is a randomized clinical trial funded by the National Heart Lung and Blood Institute to evaluate the effects of stress management training (SMT) on changes in biomarkers of risk and quality of life for patients enrolled in traditional exercise-based cardiac rehabilitation (CR).

METHODS

One hundred fifty cardiac patients recruited from Duke University and the University of North Carolina will be evaluated and randomized to CR enhanced by SMT (including sessions devoted to relaxation training, cognitive restructuring, communication skills, and problem solving) or to standard exercise-based CR. Before and after 12 weeks of treatment, patients will undergo a battery of psychometric questionnaires and evaluation of cardiovascular biomarkers, including measures of flow-mediated dilation, heart rate variability, baroreflex sensitivity, platelet function and inflammation, and ischemia during laboratory mental stress testing. The primary outcomes include a composite measure of stress (distress, depression, anxiety, and hostility and 24-hour urinary catecholamines and cortisol) and a composite measure of cardiac biomarkers of risk (vascular endothelial function, cardiac vagal control, inflammation, platelet function, and mental stress-induced myocardial ischemia). Secondary outcomes include measures of quality of life as well as clinical events, including death, hospitalizations, myocardial infarction, and revascularization procedures.

RESULTS

This article reviews prior studies in the area and describes the design of the ENHANCED study. Several key methodological issues are discussed including the assessment of biomarkers of risk and barriers to the integration of SMT into traditional CR.

CONCLUSIONS

The ENHANCED study will provide important information by determining to what extent SMT combined with exercise-based CR may improve prognosis and quality of life in vulnerable cardiac patients.

The effect of cardiac rehabilitation with relaxation therapy on psychological, hemodynamic, and hospital admission outcome variables

PURPOSE

To examine the effect of a cardiac rehabilitation program with relaxation therapy (CPRT) in comparison with cardiac rehabilitation alone on psychological stress, hemodynamic variables, cardiac risk factors, and cardiac-related hospital admissions in patients with coronary artery disease.

METHODS

Patients (N = 81) were randomly assigned to either a 12-week cardiac rehabilitation program alone (CPA) or a CPRT. Perceived stress, blood pressure, heart rate, rate-pressure product value, total cholesterol level, body mass index, smoking status, and physical activity were recorded at baseline and following the 12-week intervention. Cardiac-related hospital admissions were analyzed in a 2-year follow-up.

RESULTS

Perceived stress declined in both groups, although this improvement was significantly superior in the CPRT (31.5 +/- 4.9 vs 23.4 +/- 4.1; P <or= .0001). CPRT, but not CPA, had significantly lower heart rate, blood pressure, and rate-pressure product values after the program (P <or= .0001). Both groups improved smoking status, physical activity, body mass index, and total cholesterol level. During follow-up, the odds of being admitted to the hospital with cardiac-related problems, after adjusting for heart rate, blood pressure, smoking status, physical activity status, and total cholesterol (OR, 0.37; 95% CI, 0.045-2.98), was not significantly different between groups.

CONCLUSIONS

Relaxation therapy was associated with a positive effect on psychological stress and hemodynamic variables beyond that promoted by cardiac rehabilitation alone.

Social support group attendance is related to blood pressure, health behaviours, and quality of life in the Multicenter Lifestyle Demonstration Project

Changes in coronary risk factors, health behaviours, and health-related quality of life (HRQOL) were examined by tertiles of social support group attendance in 440 patients (21% females) with coronary artery disease. All patients participated in the Multicenter Lifestyle Demonstration Project (MLDP; eight hospital sites in the USA), an insurance-covered multi-component cardiac prevention program including dietary changes, stress management, exercise and group support for 1 year. Significant improvements in coronary risk factors, health behaviours, and HRQOL were noted at 1 year. Several of these improvements (i.e. systolic blood pressure, health behaviours, HRQOL) were related to social support group attendance, favoring those who attended more sessions. The associations between support group attendance to systolic blood pressure and to four HRQOL subscales (bodily pain, social functioning, mental health, and the mental health summary score) remained significant when controlling for changes in health behaviours, but dropped to a non-significant level for the HRQOL subscales 'physical functioning', 'general health' and 'role-emotional'. These results suggest an independent relationship of social support group attendance to systolic blood pressure while improvements in quality of life may be in part due to improved health behaviours facilitated by increased social support group attendance.

Depression and anxiety associated with cardiovascular disease among persons aged 45 years and older in 38 states of the United States, 2006

OBJECTIVE

To highlight the close association of cardiovascular disease (CVD) with depression and anxiety in US non-institutionalized adults and examine the sociodemographic correlates of depression and anxiety among CVD survivors.

METHOD

The data were obtained from 38 states which administered an Anxiety and Depression Module as part of the 2006 Behavioral Risk Factor Surveillance System. CVD was assessed with three questions on coronary heart disease and stroke. Adjusted prevalence ratios (APRs) were obtained after adjustment for demographic characteristics using SUDAAN 9.0.

RESULTS

The prevalence of a CVD history was 15.3% among studied population (sample size n=129,499). Persons with a CVD history were more likely than those without to experience current depression (15.8% versus 7.1%, APR [95% CI]=1.69 [1.54-1.85]), to have a lifetime diagnosis of depressive disorders (22.3% versus 15.1%, APR [95% CI]=1.56 [1.45-1.67]) or anxiety disorders (16.6% versus 10.0%, APR [95% CI]=1.46 [1.37-1.54]). CVD survivors with low education attainment or minority background were less likely to receive a diagnosis of depression though their experience of depression was comparable with or higher than their counterparts.

CONCLUSION

CVD is associated significantly with depression and anxiety. Disparities exist among CVD survivors on the diagnosis of depression and anxiety.

Effects of a stress management program on vital exhaustion and depression in women with coronary heart disease: a randomized controlled intervention study

OBJECTIVES

Psychosocial factors, including depression and vital exhaustion (VE) are associated with adverse outcome in coronary heart disease (CHD). Women with CHD are poor responders to psychosocial treatment and knowledge regarding which treatment modality works in them is limited. This randomized controlled clinical study evaluated the effect of a 1-year stress management program, aimed at reducing symptoms of depression and VE in CHD women.

DESIGN

Patients were 247 women, < or =75 years, recruited consecutively after a cardiac event and randomly assigned to either stress management (20 2-h sessions) and medical care by a cardiologist, or to obtaining usual health care as controls. Measurements at; baseline (6-8 weeks after randomization), 10 weeks (after 10 intervention sessions), 1 year (end of intervention) and 1-2 years follow-up.

RESULTS

For VE, intention to treat analysis showed effects for time (P < 0.001) and time x treatment interaction (P = 0.005), reflecting that both groups improved over time, and that the decrease of VE was more pronounced in the intervention group. However, the level of VE was higher in the intervention group than amongst controls at baseline, 22.7 vs. 19.4 (P = 0.036) but it did not differ later. The change in depressive symptoms did not differ between the groups.

CONCLUSIONS

CHD women attending our program experienced a more pronounced decrease in VE than controls. However, as they had higher baseline levels, due to regression towards the mean we cannot attribute the decrease in VE to the intervention. Whether the program has long-term beneficial effects needs to be evaluated.

A critical realist approach to understanding and evaluating heart health programmes

Secondary prevention programmes for Coronary Heart Disease (CHD) aim to reduce cardiovascular risks and promote health in people with heart disease. Though programmes have been associated with health improvements in study populations, access to programmes remains low, and quality and effectiveness is highly variable. Current guidelines propose significant modifications to programmes, but existing research provides little insight into why programme effectiveness varies so much. Drawing on a critical realist approach, this article argues that current research has been based on an impoverished ontology, which has elements of positivism, does not explore the social determinants of health or the effects on outcomes of salient contextual factors, and thereby fails to account for programme variations. Alternative constructivist approaches are also weak and lacking in clinical credibility. An alternative critical realist approach is proposed that draws on the merits of subjectivist and objectivist approaches but also reflects the complex interplay between individual, programme-related, socio-cultural and organizational factors that influence health outcomes in open systems. This approach embraces measurement of objective effectiveness but also examines the mechanisms, organizational and contextual-related factors causing these outcomes. Finally, a practical example of how a critical realist approach can guide research into secondary prevention programmes is provided.

Does dissociation of emotional and physiological reactivity predict blood pressure change at 3- and 10-year follow-up?

One of the major theories of psychosomatic medicine is that pervasive dissociations between physiological reactivity and simultaneous emotion awareness may be an important marker for the long-term development of cardiac problems. Subjective autonomic discrepancy (SAD) scores are proposed as a method of capturing the dissociation between physiological and emotional reactivity and increasing the explanatory power of predictive models of cardiac health outcomes. It was found that SAD scores for blood pressure indices show trait-like stability over a period of 3 years. Although linear 3-year prediction of systolic blood pressure came close to traditional definitions of significance, neither a linear nor a quadratic model was found to show significant prospective validity in predicting ambulatory blood pressure change over a 10-year period. Dissociation between physiological arousal and emotional awareness does not appear to be an important variable in the identification of individuals at risk for later cardiovascular health problems.

The contribution of changes in diet, exercise, and stress management to changes in coronary risk in women and men in the Multisite Cardiac Lifestyle Intervention Program

BACKGROUND

The relative contribution of health behaviors to coronary risk factors in multicomponent secondary coronary heart disease (CHD) prevention programs is largely unknown.

PURPOSE

Our purpose is to evaluate the additive and interactive effects of 3-month changes in health behaviors (dietary fat intake, exercise, and stress management) on 3-month changes in coronary risk and psychosocial factors among 869 nonsmoking CHD patients (34% female) enrolled in the health insurance-based Multisite Cardiac Lifestyle Intervention Program.

METHODS

Analyses of variance for repeated measures were used to analyze health behaviors, coronary risk factors, and psychosocial factors at baseline and 3 months. Multiple regression analyses evaluated changes in dietary fat intake and hours per week of exercise and stress management as predictors of changes in coronary risk and psychosocial factors.

RESULTS

Significant overall improvement in coronary risk was observed. Reductions in dietary fat intake predicted reductions in weight, total cholesterol, low-density lipoprotein cholesterol, and interacted with increased exercise to predict reductions in perceived stress. Increases in exercise predicted improvements in total cholesterol and exercise capacity (for women). Increased stress management was related to reductions in weight, total cholesterol/high-density lipoprotein cholesterol (for men), triglycerides, hemoglobin A1c (in patients with diabetes), and hostility.

CONCLUSIONS

Improvements in dietary fat intake, exercise, and stress management were individually, additively and interactively related to coronary risk and psychosocial factors, suggesting that multicomponent programs focusing on diet, exercise, and stress management may benefit patients with CHD.

Psychosoziale Aspekte und Gesundheitsverhalten bei Herzinsuffizienz

Zusammenfassung. Für die steigende Zahl von Patienten mit Herzinsuffizienz stehen verschiedene medizinische Behandlungsansätze zur Verfügung, darunter als letzte Option die Herztransplantation (HTX). Ergänzende psychosoziale und behaviorale Interventionen erscheinen aus verschiedenen Gründen auch für Patienten auf der HTX-Warteliste sinnvoll. Unser Literaturüberblick zeigt, dass bekannte psychosoziale koronare Risikofaktoren wie Depressivität und soziale Isolation auch bei Herzinsuffizienz Morbidität und Mortalität erhöhen. Körperliche Aktivität wirkt sich dagegen günstig auf subjektive und objektive Parameter aus. Diese Faktoren stellen erste Ansatzpunkte für verhaltensorientierte Interventionen dar. Welche Rolle andere koronare Risikofaktoren (z.B. Feindseligkeit, Ärger, Ernährung und Gewichtsreduktion) spielen, ist bislang ungeklärt. Ausblickend werden einige viel versprechende Forschungsansätze skizziert.

Anti-depressive Therapies After Heart Transplantation

OBJECTIVE

Despite an improved quality of life, about 33% of heart transplant recipients will develop depressive symptoms post-operatively. To date, no review has explored the efficacy and safety of pharmacologic or psychologic interventions in this patient group.

METHODS

We conducted a comprehensive Medline, EmBase, Psycinfo search for studies of the treatment of depression in heart transplant recipients.

RESULTS

We identified 34 studies of variable methodologic quality. Selective serotonin re-uptake inhibitors (SSRIs), particularly citalopram and new-generation anti-depressants (mirtazapine), seem to represent the best therapeutic choices for this population. Tricyclic anti-depressants (TCAs), and electroconvulsive therapy (ECT) should be reserved for severe depression unresponsive to other treatments, whereas monoamine oxidase inhibitors (MAOIs) should be avoided. St John's wort, an alternative herbal drug, has been associated with life-threatening immunosuppression. Psychologic therapy offers further advantages after heart transplantation.

CONCLUSIONS

Further well-conducted, randomized, controlled trials are needed to clarify the efficacy and the safety of pharmacologic (SSRIs and atypical anti-depressants) and psychologic interventions in the management of depression after heart transplantation.

Women in cardiac rehabilitation: outcomes and identifying risk for dropout

BACKGROUND

Women are underrepresented in cardiac rehabilitation (CR). Few reports describe outcomes and explore factors that may be barriers to CR participation among women. The purposes of this study were to (1) compare baseline characteristics between women who completed and did not complete CR, (2) identify factors associated with women completing CR, and (3) describe outcomes among completers.

METHODS

Study sample included women (n = 228) with coronary heart disease enrolled in CR at an academic medical center's program (January 1996-August 2003). Baseline differences between completers and noncompleters were compared; multivariate regression analyses identified factors associated with completers. Outcome measures included lipid levels, 6-minute walk distances, body mass index, Beck Depression Inventory II (BDI-II), self-reports of diet, physical activity, smoking, and perceived health status.

RESULTS

Mean age was 62 +/- 11 years, 44% were nonwhite, and 42% were stratified as high risk. Dyslipidemia was the most common risk factor (85%) followed by hypertension (81%), low physical activity (74%), obesity (53%), diabetes (39%), and smoking (18%). BDI-II scores were elevated (> or = 14) in 31% of women. In the adjusted multivariate regression model, completers were less likely to be obese (adjusted odds ratio [AOR] 0.28, CI 0.10-0.76, P = .01) or have elevated BDI-II scores (AOR 0.87, CI 0.81-0.95 P = .001) than noncompleters. Completers achieved significant improvements in all outcome measures (all P < .05) except for high-density lipoprotein.

CONCLUSION

Women enrolled in CR had a high risk factor burden and those completing achieved significant benefits. Women not completing CR were more likely to be obese or have depressive symptoms which may serve as barriers to completing CR.

A realist study of the mechanisms of cardiac rehabilitation

AIM

The aim of this paper is to report patients' experiences of cardiac rehabilitation and perceptions of the mechanisms and contexts influencing its long-term effectiveness.

BACKGROUND

Cardiac rehabilitation programmes for the secondary prevention of coronary heart disease are common. The effects of these programmes, however, can be inconsistent and little is known of the personal and contextual factors that influence service effectiveness.

METHOD

Forty-seven participants with a formal diagnosis of coronary heart disease who had attended a programme of cardiac rehabilitation in Scotland 3 years previously were included in focus groups to discuss their perceptions and experiences (30 males and 17 females). The data were generated in 2002 and analysed using the realist approach of Pawson and Tilley (1997).

RESULTS

Participants' accounts indicated that the didactic content of cardiac rehabilitation was not strongly linked to longer-term health behaviour change. The main positive effects of cardiac rehabilitation were related to the effect of participation on mediating social and body-focused mechanisms that were triggered when the rehabilitation setting was perceived to be safe. Social mechanisms identified included social comparisons, camaraderie, and social capital. Body-focused mechanisms included greater knowledge of personal physical boundaries and a greater trust in the heart-diseased body. Collectively, these mechanisms had a positive effect on confidence that was perceived as being imperative to maintain health behaviour change.

CONCLUSIONS

More support is required to promote health behaviour change after the completion of cardiac rehabilitation. Use of community-based exercise services and conventional or web-based support groups for coronary heart disease patients should be encouraged, as these appear to extend the positive health effects of the mechanisms that promote behaviour change. At the completion of cardiac rehabilitation programmes, patients should be referred to safe and appropriate community-based exercise services. Further research is needed to examine the effects on health outcomes of mechanisms and contexts related to cardiac rehabilitation.

Long-term effects of lifestyle behavior change in coronary artery disease: effects on recurrent coronary events after percutaneous coronary intervention

This study evaluated the effects of a behaviorally oriented cardiac rehabilitation and secondary prevention program on lifestyle changes and on coronary recurrence rates. Patients recently treated with percutaneous coronary intervention (PCI) were randomized to an intervention with an aggressive focus on lifestyle changes (smoking, diet, exercise, and stress; n=46) or to a standard-care control group (n=42). Results showed that the intervention group had significantly larger overall lifestyle changes than the control group after 12, 24, 36, and 60 months. The intervention group had significantly lower rates of all coronary events (acute myocardial infarction, coronary artery bypass graft, PCI, cardiac death; 30.4% vs. 53.7%), and of cardiovascular mortality (2.2% vs. 14.6%). The need for future large-scale and long-term evaluations of lifestyle-oriented secondary prevention interventions of this kind is emphasized.

Complementary and alternative medicine (CAM) use patterns and disclosure to physicians in acute coronary syndromes patients

This study assessed the frequency and types of CAM therapies used by patients hospitalized with acute coronary syndromes for general health purposes and cardiac reasons. We profiled CAM users including gender differences and degree of disclosure with treating physicians'. Data collection occurred via semi-structured interview and included demographics, past medical history, CAM use, physician visits, and patient-physician communications. Eight hundred and forty-six patients were screened for eligibility with 223 patients meeting eligibility criteria and completing data collection. Sixty-three percent of this sample used at least one CAM therapy for general health purposes in the year prior to the index hospitalization. Only 11.7% of patients reported using CAM for cardiac specific reasons. Women were more likely to use CAM relative to men and also tended to use a greater number of CAM therapies. More than one third (35.9%) of the patients that used CAM therapies did not inform their physician. Only a small fraction of CAM use was specific to cardiovascular health. These data suggest that a significant portion of patients do not report CAM use to their physicians and physicians seldom ask.

Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors

Comprehensive cardiac rehabilitation reduces mortality and morbidity but is utilised by only a fraction of eligible cardiac patients, with the participation rate of women being only about half that of men. This quantitative review assesses 32 studies meeting inclusion criteria, describing 16,804 patients, 5882 of whom were female. It was found that the main predictor of referral to a cardiac rehabilitation programme was the physician's endorsement of the effectiveness of such a programme. Patients were more likely to participate in rehabilitation programmes when they were actively referred, educated, married, possessed high self efficacy, and when the programmes were easily accessible. Patients were less likely to participate when they had to travel long distances to participate in a cardiac rehabilitation programme, or experienced guilt over family obligations. Women were less often referred and participated less often even after referral. In conclusion, many of the observed predictors, including those particular to women, are potentially modifiable with the help of health professionals.

[Improving the outcome of bipolar disorder through non-pharmacological strategies: the role of psychoeducation]

The present paper addresses the efficacy of psychoeducation and related strategies in bipolar disorders. Recently, several randomised clinical trials have shown the efficacy of psychological interventions--namely identification of prodromal signs, cognitive-behavioral therapy, psychoeducation and family-focused interventions--as a prophylactic add-on to medication. All these studies are presented hereby, together with the pioneer studies in the field. There are several topics that every psychoeducational program should include to ensure its usefulness, and they will be summarized in twelve points. Roughly, psychoeducation should contain general information about bipolar illness, compliance enhancement elements, teaching on early recognition of relapses and lifestyle regularity issues. Nowadays, several treatment guidelines include psychoeducation as a crucial prophylactic tool. Clinicians should be aware of this and start performing psychoeducation in their everyday clinical practice.

Hypnotherapeutic ego strengthening with male South African coronary artery bypass patients

Morbidity (i.e., elevated anxiety and depression) is a common feature of coronary artery bypass surgery (CABS) patients, pre- and postoperatively. Since hypnotherapy can possibly reduce morbidity in CABS patients, the aim of this study was to determine the feasibility of hypnotherapeutic ego strengthening (HES) to facilitate patient coping with concomitant anxiety and depression. Fifty patients were randomly assigned to a non-intervention control group (n = 25) and an experimental group (n = 25) and exposed to a pre- and postoperative HES intervention. Anxiety and depression were assessed with the Beck Depression Inventory and Profile of Mood States, administered preoperatively, at discharge, and at 6-week follow-up. Findings confirmed large practical reductions of anxiety and depression in the experimental group and were maintained at follow-up, while a trend towards increased depression levels occurred in the control group. Although not generalizable, results suggest broadened applications of hypnotherapy with patients in cardiac centers.

Type D personality predicts death or myocardial infarction after bare metal stent or sirolimus-eluting stent implantation

OBJECTIVES

We investigated the effect of Type D personality on the occurrence of adverse events at nine months in patients with ischemic heart disease (IHD) after percutaneous coronary intervention (PCI) with sirolimus-eluting stents (SESs) or bare stents. Type D patients experience increased negative emotions and tend not to express these emotions in social interactions.

BACKGROUND

The SES is a new advent in interventional cardiology that reduces the restenosis rate and the risk of a major adverse cardiac event, but the SES has not been shown to confer any benefits on death or myocardial infarction (MI).

METHODS

Consecutive patients with IHD (n = 875) enrolled in the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed the Type D Personality Scale (DS14) six months after PCI. The end point was a composite of death and MI. Events occurring before administration of the DS14 were excluded from analyses.

RESULTS

At nine months' follow-up, there were 20 events. Type D patients were at a cumulative increased risk of adverse outcome compared with non-Type D patients: 5.6% versus 1.3% (p < 0.002). Type D personality (odds ratio [OR] 5.31; 95% confidence interval [CI] 2.06 to 13.66) remained an independent predictor of adverse outcome adjusting for all other variables, including SES versus bare-stent implantation.

CONCLUSIONS

Type D personality was an independent predictor of adverse events in patients optimally treated with the latest advent in interventional cardiology. The DS14 could be used as a screening instrument in routine clinical practice to optimize risk stratification in IHD patients.

Screening for psychosocial risk factors in patients with coronary heart disease???recommendations for clinical practice

Psychosocial risk factors like low socio-economic status, chronic family or work stress, social isolation, negative emotions (e.g., chronic depression or acute anxiety), and negative personality patterns such as Type-D-pattern or hostility, may contribute significantly to the development and adverse outcome of coronary heart disease. Therefore, systematic screening for psychosocial risk factors in cardiological practice is recommended in order to initiate adequate intervention strategies, e.g., to involve additional psychosocial counselling or treatment. Reliable methods to assess psychosocial risk factors are: (1) standardized, structured interviews; (2) standardized questionnaires, and (3) 'single-item' questions to be included into the cardiologists' clinical interviews. While structured interviews should be restricted to trained professionals, questionnaires are easily to administer, and have frequently been used in the field of cardiology. 'Single item' questions are sufficiently reliable and the most timesaving way to screen for psychosocial factors. For clinical practice, a two-step evaluation is recommended: firstly, cardiologists should include 'single-item' questions into their routine interview and/or use questionnaires in order to screen for a potential problem. Secondly, if problems are indicated, patients should be passed to qualified professionals for structured clinical interview. Instruments of all three methods are briefly presented, and implications for further treatment are discussed.

Mental health issues associated with cardiovascular disease in women

Cardiovascular disease is the leading cause of death in women and men. However, cardiovascular disease and its treatment affect women differently. Much data is emerging regarding the role that mood and anxiety disorders play in the development and prognosis of cardiovascular disease. Pharmacologic treatment of psychiatric disorders can also have direct cardiac effects. The good news is that many more studies are exploring this. However, further research is clearly needed, especially in the area of reproductive hormones and their impact on cardiac disease.

Psychosocial distress and impaired quality of life ??? targets neglected in the secondary prevention in women with ischaemic heart disease

BACKGROUND

Secondary prevention in patients with ischaemic heart disease (IHD) focusing on classical risk factors has been less successful in women than in men. Previous studies have suggested that psychosocial factors may be new targets for secondary prevention. In the present study, psychosocial factors have been compared in women with and without IHD.

METHODS AND SUBJECTS

Using a cross-sectional comparison, classical cardiovascular risk factors and self-rated stress behaviour, vital exhaustion, stressful life events and quality of life were assessed in 198 women (age 35-77 years) who had IHD and a population-based sample of 206 women (age 45-74 years) without IHD.

RESULTS

Control of classical risk factors was most often adequate in women with IHD. The prevalence of smoking was 9% in women with versus 18% in women without IHD (P<0.001), blood pressure levels were similar, and a very large share of women with IHD were on treatment with anti-thrombotic, anti-hypertensive and/or lipid-lowering drugs (P<0.001 compared with women free of IHD). In contrast, women with IHD scored significantly worse than women without IHD in self-rated stress behaviour (P=0.003 after adjustment for other possible determinants), and in vital exhaustion (P=0.003). In univariate analyses, quality of life was significantly worse in women with IHD. Stressful life events did not differ between the two groups.

CONCLUSIONS

In this group of women with IHD, control of classical risk factors was good, whereas control of psychosocial risk factors was clearly inadequate. Secondary prevention by psychosocial intervention in women with IHD should be evaluated in randomized controlled trials.

Type D personality, cardiac events, and impaired quality of life: a review

BACKGROUND

Psychological distress has been associated with the pathogenesis and progression of coronary heart disease (CHD) but little is known about the determinants of distress as a coronary risk factor. Although it has become unfashionable to focus on personality factors since research on Type A behaviour yielded inconsistent findings, personality may comprise a major explanatory factor of individual differences in stress-related CHD. This article focuses on Type D--the distressed--personality, which describes patients who experience increased negative emotions and tend to inhibit the expression of these emotions in social interactions.

METHODS

The article reviews research on Type D personality in the context of CHD.

RESULTS

Accumulating evidence indicates that cardiac patients with the Type D personality are at increased risk for cardiovascular morbidity and mortality (odds ratios ranging from 4.1-8.9, P<0.0001) independent of standard cardiac risk factors. Type D patients are also at increased risk for psychological distress, clustering of psychosocial risk factors, impaired quality of life, and seem to benefit less from medical and invasive treatment. Preliminary evidence suggests that physiological hyper-reactivity and activation of pro-inflammatory cytokines may be responsible for the detrimental effect of Type D personality on cardiac prognosis.

CONCLUSIONS

There is an urgent need to adopt a personality approach in the identification of patients at risk for stress-related cardiac events. Type D is a stable personality construct that may be of special interest not only in CHD, but in other chronic cardiac conditions as well.

Improvement in medical risk factors and quality of life in women and men with coronary artery disease in the Multicenter Lifestyle Demonstration Project

This study examined medical and psychosocial characteristics of 440 patients (mean age 58 years, 21% women) with coronary artery disease at baseline and at 3-month and 12-month follow-ups. All patients were participants in the Multicenter Lifestyle Demonstration Project, aimed at improving diet (low fat, whole foods, plant-based), exercise, stress management, and social support. Spousal participation was encouraged. Both genders evidenced significant improvements in their diet, exercise, and stress management practices, which they maintained over the course of the study. Both women and men also showed significant medical (e.g., plasma lipids, blood pressure, body weight, exercise capacity) and psychosocial (e.g., quality of life) improvement. Despite their worse medical, psychosocial, and sociodemographic status at baseline, women's improvement was similar to that of men's. These results demonstrate that a multi-component lifestyle change program focusing on diet, exercise, stress management, and social support can be successfully implemented at hospitals in diverse regions of the United States. Furthermore, this program may be particularly beneficial for women with coronary artery disease who generally have higher mortality and morbidity than men after a heart attack, angioplasty, or bypass surgery.

The Perceived Benefits of a Group CBT Intervention for Patients With Coronary Heart Disease

Participants in a group CBT intervention for men who had undergone stent surgery completed an evaluation of the program at its completion. The evaluation included questions on how much they liked the program, how helpful they found it to be, how well the leader ran the group, what aspects of the program they had found beneficial, and what aspects they liked and disliked. Measures of anxiety, depression, and hostility were taken before and after the intervention. Participants rated the program highly and most frequently cited the opportunity to disclose and share information with fellow participants as an aspect of the program which they particularly liked. Learning specific skills was the most frequently cited benefit of doing the program. The therapeutic aims of the program—reducing anxiety, depression, and hostility—were mentioned infrequently. Although reductions in anxiety and hostility scores were apparent after the program, these were not related to participants’ feedback on the perceived benefits or enjoyable aspects of the program.