Cardiac rehabilitation: a review of current developments

Like clouds in a windy sky: Mindfulness training reduces negative affect reactivity in daily life in a randomized controlled trial

While prior research has found mindfulness to be linked with emotional responses to events, less is known about this effect in a non-clinical sample. Even less is known regarding the mechanisms of the underlying processes: It is unclear whether participants who exhibit increased acceptance show decreased emotional reactivity (i.e., lower affective responses towards events overall) or a speedier emotional recovery (i.e., subsequent decrease in negative affect) due to adopting an accepting stance. To address these questions, we re-analysed two Ambulatory Assessment data sets. The first (N_Study1 = 125) was a 6-week randomized controlled trial (including a 40-day ambulatory assessment); the second (N_Study2 = 175) was a 1-week ambulatory assessment study. We found state mindfulness to be more strongly associated with emotional reactivity than with recovery, and that only emotional reactivity was significantly dampened by mindfulness training. Regarding the different facets of mindfulness, we found that the strongest predictor of both emotional reactivity and recovery was non-judgemental acceptance. Finally, we found that being aware of one's own thoughts and behaviour could be beneficial or detrimental for emotional recovery, depending on whether participants accepted their thoughts and emotions. Together, these findings provide evidence for predictions derived from the monitoring and acceptance theory.

Setting up and Auditing Guideline- and Evidence-Based Cardiac Rehabilitation

Background: Rehabilitation is available to only a minority of post-myocardial infarction (MI) patients and is of variable quality. Guidelines now recommend individualised care delivered by hospital, primary care and community services, but there is little evidence of the feasibility, acceptability or effectiveness of this approach.

Aims: To demonstrate the feasibility of guideline-based rehabilitation, to audit delivery and outcome and to identify problems.

Methods: A four-phase stepped programme for post-MI patients was developed based on individualised in-hospital care and aftercare from a menu of options. Delivery involved co-ordination between hospital services, primary care and community services. Self-report audit data were collected in hospital and at 3 months post-discharge by postal questionnaire and telephone calls. Clinical information was recorded from hospital, telephone and outpatient contacts. Delivery of care to patients receiving interventions was recorded.

Results: It was possible to negotiate individualized plans for all patients and to monitor progress for 3 months after discharge. The rehabilitation team achieved high rates of delivery of agreed interventions, considerably better than delivery by primary care. Problems largely related to difficulties and failures in communication. Patients with major social or psychological difficulties were the most difficult to treat.

Conclusion: Guideline-based rehabilitation is feasible, but there is a need to improve the coordination of delivery of later steps of care and also to refine specialist interventions.

Physical activity after myocardial infarction: is it related to mental health?

BACKGROUND

Physical inactivity and poor mental wellbeing are associated with poorer prognoses in patients with cardiovascular disease. We aimed to analyse the cross-sectional and prospective associations between physical activity and mental wellbeing in patients with a history of myocardial infarction.

DESIGN

Longitudinal, observational study.

METHODS

We investigated 600 older subjects with a history of myocardial infarction (age range 60-80 years) who participated in the Alpha Omega Trial (AOT). They were tested twice at baseline and at 40 months follow-up for physical activity - with the Physical Activity Scale for the Elderly (PASE); depressive symptoms - with the Geriatric Depression Scale (GDS-15); and dispositional optimism - with the Life Orientation Test (LOT-R). Linear (multilevel) and logistic regression analyses were used to examine cross-sectional and longitudinal associations.

RESULTS

Physical activity was cross-sectionally associated with depressive symptoms (adjusted beta = -0.143; p = 0.001), but not with dispositional optimism (adjusted beta = 0.074; p = 0.07). We found a synchrony of change between physical activity and depressive symptoms (adjusted beta = -0.155; p < 0.001), but not with dispositional optimism (adjusted beta = 0.049; p = 0.24). Baseline physical activity did not predict depressive symptoms at 40 months follow-up.

CONCLUSIONS

Concordant inverse associations were observed for (changes) in physical activity and depressive symptoms. Physical activity did not predict depressive symptoms or low optimism.

Adoption of community-based cardiac rehabilitation programs and physical activity following phase III cardiac rehabilitation in Scotland: a prospective and predictive study

Little is known about levels of physical activity and attendance at phase IV community-based Cardiac Rehabilitation (CR) programs following completion of exercise-focussed, hospital-based phase III CR. This study aims to test, compare and combine the predictive utility of the Common-Sense Self-Regulation Model (CS-SRM) and the extended Theory of Planned Behaviour (TPB) with action planning for two rehabilitation behaviours: physical activity and phase IV CR attendance. Individuals diagnosed with coronary heart disease (n = 103) completed baseline measures of illness perceptions, intentions, perceived behavioural control (PBC), action planning and past physical activity in the last week of a phase III CR program, and 95 participants completed follow-up measures of physical activity and attended phase IV CR (objectively confirmed) 2 months later. Only one predictor (PBC/cyclical timeline) significantly predicted levels and change of physical activity. While illness perceptions were not predictive of phase IV CR attendance, the extended TPB model showed good predictive power with action planning and intention as the most powerful predictors. Amongst participants who planned when and where to attend phase IV CR at the end of phase III rehabilitation, 65.9% subsequently attended a phase IV CR program compared to only 18.5% of those who had not made a plan. This study adds to our understanding of cardiac rehabilitation behaviour after completion of health service delivered programs. Comparing theoretical models and rehabilitation behaviours contributes to the development of behaviour theory.

Health-Related Quality of Life and Health Management

The present article discusses the nature of quality of life (QOL) in general and critically evaluates its application in the area of health and illness. As regards health related quality of life (HRQoL), it is now widely recognised that treating a disease in a purely biomedical framework, where emphasis is only on curing the disease and on providing prolonged life to the patient, is not sufficient. Now the focus is also on how to enhance the QOL of patients. In this context this article attempts to identify and critically evaluate some of the contemporary issues relevant in the area of HRQoL. The issues covered in this article include relatively simple issues related to the meaning, importance, usefulness and prevalent approaches in the area of HRQoL research and complex issues such as (i)who would be accountable for a patient’s HRQoL (ii)being HRQoL stable or it changing over time (response shift) for people facing chronic diseases and (iii)whether gender differences exist in this regard. Lastly, the article also discusses the implication of HRQoL in the area of health management and intervention.

Stress management in the difficult patient encounter

Patient care and management can present a significant source of stress for the practicing dentist. This article presents the various facets and underpinnings of stress, followed by an overview of the physiologic phenomena attending the classic stress response, with an examination of the interplay between the psychologic components of stress and its influences on the development or exacerbation of somatic disorders. In addition, the characteristics that can be attributed to the patient and the practitioner that give rise to difficult encounters are explored, with an eye toward proper professional management. Further, the motivations of select patient personae are examined, including discussions regarding the angry patient, the anxious or demanding patient, and the noncompliant and addicted patient. The article offers suggestions for management of such patients, with short- and long-term stress management techniques.

Rehabilitation in endocrine patients: a novel psychosomatic approach

Long-standing endocrine disorders may imply a degree of irreversibility of the pathological process and induce highly individualized affective responses. The psychosocial impairment that is associated with incomplete remission from endocrine illness suggests the need for an innovative approach to treatment, introducing in clinical endocrinology the concept of rehabilitation, which in other fields of medicine is already established. This new proposal stems from a number of unresolved issues related to the high prevalence of psychosocial impairment in patients adequately treated for various endocrine conditions. Indeed, rehabilitation in endocrinology may be indicated in the following cases: (a) delayed recovery after appropriate treatment; (b) discrepancy between endocrine status and current functioning; (c) presence of a decline in physical and social functioning; (d) persistence of important comorbidity, with special reference to psychiatric disturbances; (e) assessment of abnormal illness behavior; (f) problems with lifestyle and risk behavior, and (g) potential role of stress in endocrine disturbances. The endocrine rehabilitation team should ideally include a trained clinical endocrinologist, a physical therapist and a psychologist, with opportunities for other specialist consultations. The goal of such service would be to ensure education, support and specific interventions, helping the patient and his/her family to achieve optimal coping with the difficulties of the recovery process. Due to its comprehensive psychosomatic characterization, this new approach would likely increase the chances of obtaining full recovery in a significant proportion of patients and has the potential of being cost-effective.

Physical activity and depressive symptoms in cardiac rehabilitation: Long-term effects of a self-management intervention

Long-term effects of a self-management intervention on physical activity and depressive symptoms were studied in 198 men and women after cardiac rehabilitation in Germany. Participants were randomly assigned to either an intervention group or a standard-care control group. The intervention group received brief self-regulatory skills training that focused on exercise planning strategies. Four and 12 months later, physical exercise levels were half a standard deviation higher in the intervention group. Depressive symptoms 12 months after discharge were almost half a standard deviation lower in the intervention group than in the control group. Mediation analyses were performed to study the potential mechanism that accounted for the reduction in depression. Perceived attainment of exercise goals, but not physical exercise itself, emerged as a mediator between the intervention and the reduction of depressive symptoms. As such attainment of personal goals appears to be of particular importance for lowering depressive symptoms during health-behavior change. Thus, self-management strategies to help patients attain their goals should be part of rehabilitation programs.

Langzeiteffekte einer Planungs- und Handlungskontrollintervention auf die körperliche Aktivität von Herzpatienten nach der Rehabilitation

Zusammenfassung. Personen, die Intentionen haben, körperlich aktiver zu werden, scheitern oft an der Umsetzung dieser Intentionen in Verhalten. Zur Überwindung dieser “Intentions-Verhaltens-Lücke“ bieten sich die volitionalen Konstrukte Ausführungsplanung, Bewältigungsplanung und Handlungskontrolle an. Die vorliegende Studie untersuchte die Effektivität einer Intervention zur Verbesserung der Ausführungsplanung, der Bewältigungsplanung und der Handlungskontrolle auf die körperliche Aktivität ein Jahr später im Vergleich zu einer Kontrollgruppe. Weiterhin sollte anhand von Mediatoranalysen ermittelt werden, welche der drei volitionalen Konstrukte die Wirksamkeit der Intervention maßgeblich beeinflussten. Teilnehmer der Studie waren 199 Herzpatienten, die nach Entlassung aus der Rehabilitation einen körperlich aktiven Lebensstil aufnehmen und aufrechterhalten sollten und die auch über eine entsprechende Intention berichteten. Die Ergebnisse zeigen, dass die Intervention die körperliche Aktivität der Teilnehmer, verglichen mit einer Kontrollgruppe, ein Jahr später positiv beeinflusst hat. Die Handlungskontrolle mediierte den Interventionseffekt auf die körperliche Aktivität. Implikationen für die Übertragung der Ergebnisse in die Praxis sowie für die weitere Forschung werden diskutiert.

Impact of Type A Behavior on Brachial-Ankle Pulse Wave Velocity in Japanese

Pulse wave velocity (PWV) is the velocity of a pulse wave traveling a given distance between 2 sites in the arterial system, and is a well-known indicator of arteriosclerosis. Brachial-ankle PWV (baPWV) is a parameter more simple to obtain, compared with the conventional PWV, and is an easy and effective means of evaluating arteriosclerosis. BaPWV can be obtained by only wrapping the four extremities with blood pressure cuffs, and it can be easily used to screen a large number of subjects. Type A behavior has been confirmed as an independent risk factor for the development of coronary heart disease. To examine the relationship between Type A behavior and arteriosclerosis, 307 normal Japanese subjects were classified into either a Type A group (n = 90) or a non-Type A group (n = 217) by using Maeda's Type A Scale. BaPWV was evaluated using a PWV diagnosis device. The baPWV in the Type A group was significantly higher than that obtained in the non-Type A group. The baPWV showed a positive correlation with age both in the Type A group and in the non-Type A group; however, the straight-line regression slope of baPWV versus age in the Type A group was significantly larger than that in the non-Type A group. Therefore, our results suggest that arteriosclerosis might be promoted earlier in subjects expressing the Type A behavior pattern. Type A behavior pattern is confirmed as a risk factor for arteriosclerosis, and may increase the risk of the cardiovascular disease related to arteriosclerosis.

Stress versus discrete negative emotions in the prediction of physical complaints: Does predictive utility vary across ethnic groups?

Reports of stress and negative emotion are important predictors of health. However, whether discrete emotions or stress measures are more useful, whether they contribute independently to outcome, and whether they relate to health equally across ethnic groups remain unclear. In the current study, 207 US-born European American, US-born African American, Black English-speaking Caribbean, and Dominican men aged 40 years and older completed measures of somatic symptoms, trait emotions, and stress. Sadness and stress independently predicted symptom reports, even when examined concurrently, and with demographics controlled; trait anger did not predict symptoms. Moreover, the relations between trait emotions and symptoms varied across groups. Levels of sadness were associated with greater symptoms among US-born European American and Dominican men, but negatively associated among Black English-speaking Caribbean men, and the relations for anger also differed marginally across groups. The results underscore the importance of differentiating among discrete emotions and stress and considering ethnic interactions when examining reports of somatic symptomology. We suggest that the impact of psychological characteristics on health must be considered within cultural and ethnic contexts to be fully understood.

Long-term effects of two psychological interventions on physical exercise and self-regulation following coronary rehabilitation

In cardiac rehabilitation programs, patients learn how to adopt a healthier lifestyle, including regular, strenuous physical activity. Long-term success is only modest despite good intentions. To improve exercise adherence, a 3-group experiment was designed that included innovative psychological interventions. All 3 groups underwent a standard care rehabilitation program. Patients in the 2 treatment groups were instructed not only to produce detailed action plans but also to develop barrier-focused mental strategies. On top of this, in 1 of these groups a weekly diary was kept for 6 weeks to increase a sense of action control. At the end of a standard cardiac rehabilitation program, 240 patients were randomly assigned to these treatment groups plus a standard care control group. Treatments resulted in more physical activity at follow-up and better adherence to recommended levels of exercise intensity. Moreover, self-regulatory skills such as planning and action control were improved by the treatments. Follow-up analyses demonstrated the mediating mechanisms of self-regulatory skills in the process of physical exercise maintenance. Findings imply that interventions targeting self-regulatory skills can enable post-rehabilitation patients to reduce behavioral risk factors and facilitate intended lifestyle changes.

The uncharted waters of emotion: ethnicity, trait emotion and emotion expression in older adults

Emotions are central to contemporary theories of health, and a growing body of psychological research has shown emotion and emotion regulatory styles to be predictive of health outcomes. Yet despite these clear links and the fact that patterns of emotion and expression are partially a product of culture, there is a meager literature on the emotional characteristics of different ethnic groups. Even where ethnicity has been investigated in emotions research, it has typically been operationalized in such a way that within-group differences are obscured with most individuals assigned to broad ethnic categories, such as non-Hispanic White, or Black. In the present study we draw on data from a multi-ethnic sample of 755 community-dwelling older adults to parse a picture of the emotional characteristics of three of the largest and most culturally distinct ethnic groups in the Northeastern United States: African Americans, West Indians (Jamaicans), and Eastern Slavs (Russians and Ukrainians) from the former Soviet Republic, as well as a comparison group of US-born European Americans. As predicted, there were striking differences in nine of 10 trait emotions as well as in levels of emotion expressed during conflict. The findings are discussed in terms of emotion socialization and implications for prediction and intervention in psychosocial models of emotions, emotion regulation, and health in older ethnic populations.

Process and Outcome in Cardiac Rehabilitation: An Examination of Cross-Lagged Effects

Cardiac rehabilitation patients improve cardiorespiratory fitness and quality of life, yet therapeutic processes that produce these changes remain unknown. A cross-lagged panel design was used to determine whether early-treatment enhancement of self-efficacy regarding abilities to change diet and exercise habits and the quality of the patient-staff working alliance predicted late-treatment changes in a wide range of outcomes, but not vice versa. Eighty cardiac patients participating in a 12-week program completed measures at early, mid- and late treatment. Early-treatment changes in exercise self-efficacy predicted late-treatment changes in activity level, depression, and working alliance, but not vice versa. Diet self-efficacy changes correlated with concurrent changes in fat intake and body weight. Early-treatment changes in cardiorespiratory fitness and activity level predicted late-treatment changes in working alliance, but not vice versa. Findings suggest that increased exercise self-efficacy represents an important therapeutic mechanism by which rehabilitation gains are realized. ((c) 2004 APA, all rights reserved)

Psychological assessment in cardiac rehabilitation

BACKGROUND

While there has been an upsurge of interest in the psychiatric correlates of myocardial infarction, little is known about the presence of psychological distress in the setting of cardiac rehabilitation.

METHODS

A consecutive series of 61 patients with recent myocardial infarction who participated in a cardiac rehabilitation program was evaluated by means of both observer-rated (DSM and DCPR) and self-rated (Psychosocial Index) methods. A follow-up of this patient population was undertaken (median = 2 years). Survival analysis was used to characterize the clinical course of patients.

RESULTS

Twenty percent of patients had a DSM-IV diagnosis (in half of the cases minor depression). An additional 30% of patients presented with a DCPR cluster, such as type A behavior and irritable mood. Only high levels of self-perceived stressful life circumstances and psychological distress approached statistical significance as a psychological risk factor for cardiovascular events after myocardial infarction.

CONCLUSIONS

Psychological evaluation of patients undergoing cardiac rehabilitation needs to incorporate both clinical (DSM) and subclinical (DCPR) methods of classification. Type A behavior was present in about a quarter of patients and can be studied in specific subgroups of cardiovascular patients defined by DCPR.

Nursing approaches to reducing psychological distress in men and women recovering from myocardial infarction

This paper examines the types of nursing approaches associated with reductions in psychological distress in post-myocardial infarction patients (n=275 men; 156 women) who took part in a home-based psychosocial nursing Intervention program (Montreal Heart Attack Readjustment Trial). We found that three types of emotionally supportive approaches including reassurance/encouragement, listening and the provision of advice varied in their links to reduction in distress depending on patients' types of concerns. There were also gender differences in the way directive and collaborative intervention approaches were related to changes in distress.

Depression, Hostility, and Social Isolation in Patients with Coronary Artery Disease

Psychosocial risk factors such as depression, hostility, and social isolation are substantially more prevalent in patients with coronary artery disease (CAD) than is widely recognized. It has been demonstrated that patients with CAD who have these risk factors, individually or together, may have a substantially increased risk for recurrent ischemic events, as well as cardiac death, when compared with unaffected CAD patients. Numerous adverse physiologic changes that appear to occur as a consequence of these psychosocial risk factors have been identified, including increased platelet aggregation, hyperadrenergic states, elevated cortisol levels, abnormal endothelial function, and an increased propensity towards malignant ventricular arrhythmias. Each of these may explain the increased risk of recurrent coronary events (including death) among afflicted patients. Under-recognition, and hence under-treatment, remains a principal obstacle for improvements in the care of patients with CAD who have psychosocial risk factors. The diagnosis of psychosocial risk factors depends on systematic patient evaluation by experienced clinicians trained in the recognition of these disorders. All clinicians must be aware of the potential importance of these factors, their sometimes subtle presenting characteristics, and the available treatment options. The universal use of comprehensive cardiovascular rehabilitation offers the ideal conduit for such evaluation and management. Nonpharmacologic therapies for psychosocial risk factors include psychotherapy, stress-reduction techniques, and exercise therapy. Studies suggest that the reduction of social isolation among depressed patients with CAD may result in a reduced mortality rate in comparison with those without improvements in isolation. Pharmacologic therapies are mainly for the management of depression, and largely center on the use of selective serotonin reuptake inhibitors (SSRIs). Several SSRIs (paroxetine and sertraline) recently have been shown to be safe and effective for the treatment of depression in patients with ischemic heart disease. Whether use of antidepressants attenuate the increased cardiac risk from depression in the setting CAD remains to be proven; however, their use improves the quality of life in properly selected patients.