Enhancing emotional well-being by comprehensive rehabilitation in patients with coronary heart disease

Longitudinal association between positive affect and blood lipids in patients following acute myocardial infarction

OBJECTIVE

Unfavorable blood lipid profiles are robust risk factors in predicting atherosclerotic disease. Studies have shown that positive affect (PA) is associated with a favorable lipid profile. However, longitudinal studies regarding the course of PA and lipid profiles in myocardial infarction (MI) patients are lacking. Therefore, the aim of this study was to prospectively explore the association between PA and blood lipid levels across three inv estigations over 12 months following acute MI.

METHODS

Patients following an acute MI were examined at hospital admission (n = 190), and at 3 months (n = 154) and 12 months (n = 106) thereafter. Linear mixed effect regression models were used to evaluate the relation between PA, assessed with the Global Mood Scale, and blood lipid levels. Potential confounding variables were controlled for in the analysis.

RESULTS

Higher PA was significantly associated with higher high-density lipoprotein cholesterol (HDL-C) levels and a lower total cholesterol (TC)/HDL-C ratio over time, independent of demographic factors, indices of cardiac disease severity, comorbidity, medication use, health behaviors, serum cortisol and negative affect (p≤0.040). No association was found between PA and the two blood lipids low-density lipoprotein-cholesterol (LDL-C) and triglycerides (TG).

CONCLUSIONS

Positive affect was independently associated with HDL-C levels and the TC/HDL-C ratio in patients up to 1 year after MI. The findings support a potential role of PA for cardiovascular health through an association with a favorable blood lipid profile.

Personality Traits Predict Life Satisfaction in Coronary Heart Disease (CHD) Patients

Objectives: The objective of the current study is to establish the association between Big Five personality traits and life satisfaction in coronary heart disease (CHD) patients. Methods: The current study analyzed data from 566 patients with CHD with a mean age of 63.00 ± 15.23 years old (61.13% males) and 3018 healthy controls (63.95% females) with a mean age of 63.85 (S.D. = 9.59) years old from the UKHLS. A train-and-test approach accompanied by one-sample t-tests was used to analyze the differences in personality traits and life satisfaction between CHD patients and healthy controls while controlling for potential confounders. Two multiple regression models were applied to analyze the associations between personality traits and life satisfaction in CHD patients and healthy controls, respectively. Results: The current study found that CHD patients have lower conscientiousness scores than healthy controls. Moreover, neuroticism was negatively related to life satisfaction, and agreeableness, conscientiousness, and extraversion were positively related to life satisfaction in healthy controls. However, only neuroticism and agreeableness were related to life satisfaction in CHD patients. Conclusion: Health professionals and clinicians should utilize findings from the current study to make customized interventions based on CHD patients’ personality traits to gain better well-being outcomes such as life satisfaction.

Cardiac Rehabilitation and Survival for Ischemic Heart Disease

Purpose of Review

Cardiac rehabilitation (CR) referral is a Class I post-myocardial infarction (MI) recommendation from the American Heart Association and the American College of Cardiology, yet referral rates remain strikingly low, with cardiologists some of the worst under-referring offenders. This paper seeks to review the evolution of CR and its well-established benefits, as well as reasons behind the poor referral and utilization.

Recent Findings

CR is a secondary prevention program for cardiovascular disease (CVD) that was first initiated in the 1970s as a hospital-based exercise program after an acute MI, but then evolved into a comprehensive multi-disciplinary program for patients with a wider range of cardiovascular diseases. CR mortality and morbidity benefits have endured over decades, even as interventional and pharmacological cardiovascular therapeutics have improved and as patients have become relatively more stable.

Summary

Despite being an evidence-based clinical standard, referral and participation in CR are disconcertingly low. In efforts to combat poor referral rates, and improve care in the contemporary care environment, the approach to CR is evolving. Innovations include broadening CR beyond the hospital setting into remote- and hybrid-based formats, while still incorporating exercise training, risk factor reduction, and education, as well as behavioral and psychosocial support. Nonetheless, there still remain many challenges to overcome in order to increase participation of all ages, financials, races, and sexes. With new performance measures as well as an increasing number of NIH-funded studies on the horizon, there is hope that CR will become a relatively more valued and utilized component of cardiovascular preventative care.

Feelings of being disabled as a prognostic factor for mortality in men and women post-PCI up to 12years

BACKGROUND

It remains unclear whether feelings of being disabled are a relevant psychological factor that determines long term outcome after percutaneous coronary intervention (PCI). Therefore, we evaluated 'feelings of being disabled' as an independent risk factor for mortality 12years post-PCI.

METHODS

The study population comprised a consecutive series of CAD patients (n=845) treated with PCI as part of the Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) registry. Of these patients n=646 (age 63years, 75% male) completed the subscale 'feelings of being disabled' of the Heart Patients Psychological Questionnaire (HPPQ), within the first month after PCI.

RESULTS

At 12year follow-up, n=209 patients (32%) died. Of the 162 females n=73 (45%) experienced high feelings of being disabled (High-FOBD) and of the 484 males, n=134 (28%) reported high-FOBD. Patients with high feelings of being disabled had a two-fold increased risk of mortality at 12-year follow-up (HR=1.86, 95% CI=1.41-2.45). After adjusting, high feelings of being disabled remained a predictor of 12-year mortality (HR=2.53, 95% CI=1.30-4.90).

CONCLUSIONS

This study confirms that psychosocial variables like feelings of being disabled influence cardiac morbidity and mortality. Furthermore, there is no difference in mortality between men and women with high feelings of being disabled 12years post-PCI. It is important that clinicians are aware that PCI-patients who feel disabled have a less favorable survival and that the difference in survival is even greater for women who feel disabled.

Coronary Artery Bypass Graft Operation: Patients' Experience of Health and Well-Being Over Time

BACKGROUND

The aim of the coronary artery bypass graft operation is to relieve anginal symptoms and improve functional ability, quality of life and survival. However, having the surgery does not always have the desired outcomes. Although numerous studies have investigated the outcomes of coronary artery bypass graft operation, little attention has been given to patients' perceptions of the outcomes or effects of the operation on health and well-being over time.

AIM

To explore patients' perspectives on the effects of coronary artery bypass surgery on health and well-being over time.

METHODS

As part of a larger mixed methods study, 62 in-depth audio-taped interviews with men and women who had undergone coronary artery bypass approximately 7 years earlier were conducted. Interviews were audio-taped and transcribed. Data were analysed thematically. This paper reports the findings from the qualitative component of the larger study.

FINDINGS

The four main themes: 'Recovery and Rehabilitation', 'Seven Years On', 'Maintaining a Positive Approach', and 'Health Behaviour Change' reflect the main areas of focus emerging across the interviews and provide credible overarching descriptors of the sub-themes they encompass. The 11 sub-themes identified were recognised as central to the patients' experiences of their health and well-being over the longer-term.

CONCLUSIONS

Although most patients report improved health and well-being after coronary artery bypass operation, many have described their recovery and rehabilitation as a complex process with both short and long term effects. The insights provided by participants help improve our understanding of the impact of the operation on patients' health and well-being over time. We believe these insights will help us to anticipate the possible needs of future patients and enable us develop appropriate interventions that may facilitate self-management for optimal recovery and health maintenance.

[Cardiac rehabilitation after myocardial infarction]

Although the proofs of the benefits of cardiac rehabilitation accumulate, many patients are not sent to rehabilitation units, especially younger and very elderly patients. As the length of stay in acute care units decreases, rehabilitation offers more time to fully assess the patients' conditions and needs. Meta-analyses of randomised trials suggest that mortality can be improved by as much as 20-30%. In addition, rehabilitation helps managing risk factors, including hyperlipidemia, diabetes, smoking and sedentary behaviours. Physical training also helps improving exercise capacity. Because of all of these effects, cardiac rehabilitation for post-myocardial infarction patients has been given a class IA recommendation in current guidelines.

Cardiac rehabilitation past, present and future: an overview

Cardiac Rehabilitation has evolved over the past decades from a simple monitoring for the safe return to physical activities to a multidisciplinary approach that focuses on patient education, individually tailored exercise training, modification of the risk factors and the overall well-being of the cardiac patients. It has been proven to be an effective tool for the care of the patients with heart disease. Recent research in cardiac rehabilitation has demonstrated that tremendous benefits can be derived from the optimal use of cardiac rehabilitation in patients with various cardiac pathologies including ischemic heart disease, heart failure and post heart surgery. The benefits of cardiac rehabilitation include mortality reduction, symptom relief, reduction in smoking and improved exercise tolerance, risk factors modification and the overall psychosocial wellbeing. Unfortunately, cardiac rehabilitation remains considerably underutilized mainly because of referral problems and poor enrollment. The development of alternate approaches and the use of transtelephonic and other means of monitoring and surveillance will help expand the utilization of cardiac rehabilitation.

Exercise Mediates the Association Between Positive Affect and 5-Year Mortality in Patients With Ischemic Heart Disease

Background—

Positive affect has been associated with better prognosis in patients with ischemic heart disease, but the underlying mechanisms remain unclear. We examined whether positive affect predicted time to first cardiac-related hospitalization and all-cause mortality, and whether exercise mediated this relationship in patients with established ischemic heart disease.

Methods and Results—

The sample comprised 607 patients with ischemic heart disease from Holbæk Hospital, Denmark. In 2005, patients completed the Global Mood Scale (GMS) to assess positive affect and a purpose-designed question on exercise. Data on mortality and hospitalization were collected from Danish national registers for the period 2006–2010. Adjusted Cox and logistic regression were used to analyze the mediation model. Because no significant association between positive affect and cardiac-related hospitalization was found, we constructed no mediation model for hospitalization. Importantly, patients with high positive affect had a significantly reduced risk of all-cause mortality (hazard ratio, 0.58; 95% confidence interval, 0.37–0.92; unadjusted analysis) and were more likely to exercise (odds ratio, 1.99; 95% confidence interval, 1.44–2.76; unadjusted analysis; odds ratio, 1.48; 95% confidence interval, 1.03–2.13; adjusted analysis). When controlling for positive affect and other relevant variables, patients engaged in exercise were less likely to die during follow-up (hazard ratio, 0.50; 95% confidence interval, 0.31–0.80; P =0.004). Importantly, exercise acted as a mediator in the relationship between positive affect and mortality.

Conclusions—

Patients with higher levels of positive affect were more likely to exercise and had a lower risk of dying during 5-year follow-up, with exercise mediating the relationship between positive affect and mortality. Interventions aimed at increasing both positive affect and exercise may have better results with respect to patients’ prognosis and psychological well-being than interventions focusing on 1 of these factors alone.

Positive affect dimensions and their association with inflammatory biomarkers in patients with chronic heart failure

BACKGROUND

In cardiac patients positive affect has found to be associated with improved clinical outcomes, with reduced inflammation being one of the potential mechanisms responsible.

METHODS

Positive affect was assessed using The Global Mood Scale (GMS), Positive and Negative Affect Schedule (PANAS), and Hospital Anxiety and Depression Scale (HADS) in patient with chronic heart failure (N=210; 67 ± 9 years, 79% men). Markers of inflammation (TNFα, sTNFr1, sTNFr2, IL-6 and CRP) were measured and averaged at three consecutive time points.

RESULTS

The positive affect dimensions of the GMS and PANAS were significantly associated with lower averaged levels of sTNFr2, TNFα and IL-6 (p<.1), even after adjustment for clinical and lifestyle confounders. Positive affect of the HADS was significantly associated with lower averaged levels of hsCRP (p<.1), but was no longer significant after correction for lifestyle confounders and depressive symptoms.

CONCLUSION

Positive affect is associated with reduced inflammation in patients with heart failure.

[Cardiac rehabilitation after acute myocardial infarction]

At the time of evidence-based medicine, while the proofs of the benefits of cardiac rehabilitation to the coronary multiply, a large number of patients are still managed without any form of rehabilitation. In particular, younger patients with myocardial infarction treated by early reperfusion and older subjects. The objective of in-hospital or ambulatory cardiac rehabilitation is a global coverage of the patient and his/her risk factors, that the short duration of hospitalization in the acute phase does not allow. Several randomized studies, metaanalyses, and registers show a decrease from 20 to 30% of the mortality after cardiac rehabilitation. The benefits of physical training on risk factors modification are demonstrated by numerous works: improvement of lipid parameters and arterial pressure, prevention of diabetes, increased smoking cessation, loss of weight, better overall well-being; besides the management of risk factors, physical training improves exercise capacity, a recognised prognostic factor. The efficiency of cardiac rehabilitation may be comparable with that of the key treatments of coronary artery disease, such as beta-blockers or coronary angioplasty. All these proofs give to the cardiac rehabilitation in post-myocardial infarction a high-level recommendation, grade IA.

Negative and positive affect are independently associated with patient-reported health status following percutaneous coronary intervention

PURPOSE

We examined the association between negative and positive affect and 12-month health status in patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents.

METHODS

Consecutive PCI patients (n = 562) completed the Global Mood Scale at baseline to assess affect and the EuroQoL-5D (EQ-5D) at baseline and 12-month follow-up to assess health status.

RESULTS

Negative affect [F(1, 522) = 17.14, P < .001] and positive affect [F(1, 522) = 5.11, P = .02] at baseline were independent associates of overall health status at 12-month follow-up, adjusting for demographic and clinical factors. Moreover, there was a significant interaction for negative by positive affect [F(1, 522) = 6.11, P = .01]. In domain-specific analyses, high negative affect was associated with problems in mobility, self-care, usual activities, pain/discomfort, and anxiety/depression with the risk being two to fivefold. Low positive affect was only associated with problems in self-care (OR: 8.14; 95% CI: 1.85-35.9; P = .006) and usual activities (OR: 1.87; 95% CI: 1.17-3.00; P = .009).

CONCLUSIONS

Baseline negative and positive affect contribute independently to patient-reported health status 12 months post PCI. Positive affect moderated the detrimental effects of negative affect on overall health status. Enhancing positive affect might be an important target to improve patient-centered outcomes in coronary artery disease.

Feelings of being disabled as a prognostic factor for mortality in the drug-eluting stent era

OBJECTIVE

It remains unclear whether feelings of being disabled are a relevant psychological factor that determines outcome after percutaneous coronary intervention (PCI). Therefore, we evaluated "feelings of being disabled" as an independent risk factor for mortality 4 years post-PCI.

METHODS

As part of the Taxus-Stent Evaluated At Rotterdam Cardiology Hospital (T-SEARCH) Registry, 658 consecutive patients (age 63 years, 75% male) completed the subscale "feelings of being disabled" of the Heart Patients Psychological Questionnaire (HPPQ), within the first month after PCI.

RESULTS

At 4-year follow-up, 8% of the patients (n=55) had died, 2% (n=16) underwent a myocardial infarction (MI), 13% (n=90) had a target-vessel revascularization (TVR), and 21% (n=137) had one or more major adverse cardiac events (MACE). One-third of the patients (32%) had high scores on "feelings of being disabled" at baseline. After adjusting for baseline characteristics, including symptoms of anxiety and depression, patients with a high score on "feelings of being disabled" had an increased risk for all cause mortality (HR=2.9, 95% CI=1.5-5.6), the composite end point mortality/MI (HR=2.4, 95% CI=1.3-4.4), and the occurrence of MACE (HR=1.7, 95% CI=1.1-2.7).

CONCLUSION

Feelings of being disabled were an independent predictor of all-cause mortality, mortality/MI, and MACE 4 years post-PCI. These patients should be identified in clinical practice, as they warrant additional treatment, e.g., of a psychosocial nature, in addition to the standard medical treatment.

Positive affect and negative affect correlate differently with distress and health-related quality of life in patients with cardiac conditions: validation of the Danish Global Mood Scale

OBJECTIVE

The Global Mood Scale (GMS), assessing negative affect (NA) and positive affect (PA), is sensitive to tapping treatment-related changes in patients with cardiac conditions. We examined the psychometric properties of the Danish GMS and the influence of NA and PA on distress and health-related quality of life (HRQL).

METHOD

A mixed group of patients with cardiac conditions (n=502) completed the GMS, the Hospital Anxiety and Depression Scale, the Type D Scale, and the 36-item Short-Form Health Survey.

RESULTS

The two-factor model of the Danish GMS was confirmed, and the scale was shown to be valid, internally consistent (Cronbach's alpha NA/PA=.93/.85), and stable over 3 weeks (Pearson's r NA/PA=.82/.80). Unadjusted multiple linear regression analyses showed NA (beta=0.67, P<.001), PA (beta=-0.17, P=.001), and the interaction effect NA x PA (beta=-0.17, P=.015) to be associated with anxiety and depressive symptoms (NA:beta=0.99, P<.001; PA:beta=-0.12, P=.004; NA x PA:beta=-0.43, P<.001), as well as with physical HRQL (NA:beta=-0.37, P<.001; PA:beta=0.17, P=.001; NA x PA: beta=-0.27, P<.001) and mental HRQL (NA:beta=-0.72, P<.001; PA:beta=0.27, P=.004; NA x PA:beta=0.23, P<.001). When adjusting for demographic and clinical characteristics, only NA (beta=0.26, P=.003) was associated with anxiety, whereas NA (beta=0.75, P<.001) and NA x PA (beta=-0.34, P=.002) were associated with depressive symptoms. For physical HRQL, PA (beta=0.21, P=.03) and NA x PA (beta=-0.36, P=.005) remained significant, whereas NA (beta=-0.38, P<.001) and PA (beta=0.21, P=.002) remained significant for mental HRQL.

CONCLUSION

The Danish GMS is a psychometrically sound measure of affect in patients with cardiac conditions. Future studies should examine changes in both PA and NA and their impact on health outcomes.

[Cardiac rehabilitation: first experience in Algeria]

Cardiac rehabilitation should be considered part of the management of coronary artery disease patients. One is surprised, however, by the discrepancy between the proven benefits of cardiac rehabilitation and the use of cardiac rehabilitation, particularly in developing countries. This paper describes the initial experience of the first Algerian rehabilitation centre and the results achieved in the first 158 coronary patients participating in a cardiac rehabilitation programme. Overall, there was a marked improvement in functional capacity and quality of life for all patients.

An Evaluation of Two Behavioral Rehabilitation Programs, Qigong Versus Progressive Relaxation, in Improving the Quality of Life in Cardiac Patients

OBJECTIVES

The aim of the current study was to evaluate and compare two different behavioral rehabilitation programs in improving the quality of life in cardiac patients in Hong Kong.

DESIGN AND SETTING

The current study was carried out in the outpatient unit of Occupational Therapy Department in the United Christian Hospital, Hong Kong. Convenience sampling with referral from the cardiac specialty was used in the present study.

SUBJECTS

A total of 65 subjects, with a mean age 65 (range, 42 to 76), were recruited in the study. The cardiac diseases included myocardial infarct, postcoronary intervention, valve replacement, and also ischemic heart disease.

INTERVENTIONS

Patients were alternately allocated to the two groups. The first group of patients received instructions and practiced on progressive relaxation. The second group of patients underwent training in qigong. A total of eight sessions were conducted and each session lasted 20 minutes.

OUTCOME MEASURES

Demographic and clinical data such as gender, age, and systolic and diastolic blood pressure were recorded. The psychological and Quality of Life assessment was performed using the Chinese versions of Short Form 36 (C-SF36), State-Trait Anxiety Inventory (C-STAI), and General Health Questionnaire (C-GHQ-12).

RESULTS

Fifty-nine (59) subjects (44 men and 15 women) completed all eight rehabilitation sessions in the study. Patients allocated to the two treatment groups had comparable baseline characteristics. Progressive relaxation was more effective in reducing blood pressures compared to qigong. Relaxation appeared to be particularly beneficial in somatic domains. qigong group demonstrated greater improvement in psychologic measures in addition to reduction in systolic blood pressure.

CONCLUSIONS

Progressive relaxation and qigong exercise improved the quality of life for cardiac patients with reference to certain physiologic and psychologic measures. The result was supported by previous studies and literature reviews on qigong in terms of its effect on the psychologic dimension.

Positive and negative affect within the realm of depression, stress and fatigue: the two-factor distress model of the Global Mood Scale (GMS)

BACKGROUND

The Global Mood Scale (GMS; [Denollet, J., 1993a. Emotional distress and fatigue in coronary heart disease: the Global Mood Scale (GMS). Psychol Med 23, 111-121., Denollet, J., 1993b. The sensitivity of outcome assessment in cardiac rehabilitation. J Consult Clin Psychol 61, 686-695.]) was originally developed as a measure of positive affect (PA) and negative affect (NA) in cardiac patients. The purpose of this study was to examine its two-factor affect model in the realm of stress, depression, and fatigue in working adults.

METHODS

Affect, stress, depression, and fatigue were assessed with validated questionnaires in a sample of 228 adults (49.6% male; mean = 41.4 +/- 9 years) from the working population.

RESULTS

The GMS PA and NA scales were internally consistent (Cronbach's alpha = .94 and alpha = .93, respectively), and correlated in the expected direction with their corresponding mood scales from the Positive and Negative Affect Schedule (PANAS). Factor analyses of the 40 mood terms comprising the GMS and PANAS yielded one common PA-dimension, but two NA-dimensions reflecting emotional exhaustion (GMS) and anxious apprehension (PANAS) as different components of the stress process. A relatively high mean NA score of the GMS suggested that these working adults perceived terms that refer to malaise/deactivation as being relevant to describe their negative affective status. The GSM-NA scale was related to stress, depression and fatigue while the GMS-PA scale was positively associated with quality of life.

LIMITATIONS

This study is based on a cross-sectional design.

CONCLUSIONS

The association between the PA (negative correlation) and NA (positive correlation) scales of the GMS and perceived stress, depressive symptoms, and fatigue supports the validity of its two-factor model. Assessment of both PA and NA may benefit a better understanding of emotional distress in adults from the working population.

Feelings of being disabled as a risk factor for mortality up to 8 years after acute myocardial infarction

OBJECTIVE

We examined the independent prognostic value of the four subscales of the Heart Patients Psychological Questionnaire (HPPQ) on mortality in acute myocardial infarction (AMI) survivors up to 8 years after the event.

METHODS

The HPPQ, which measures well-being, feelings of being disabled, despondency and social inhibition, was administered to 567 AMI patients during hospitalisation and at 3 months follow-up. The patients were followed for 8 years.

RESULTS

During follow-up, 157 patients (28%) died. Forty-one percent of the patients had a score indicating at least mild to moderate feelings of being disabled. Patients with feelings of being disabled were at increased risk of mortality compared with those having a low score, adjusted for other cardiac risk factors [hazard ratio (HR)=1.8, 95% confidence interval (CI)=1.3-2.5]. There was no interaction between feelings of being disabled and gender. None of the other HPPQ subscales were related to mortality or recurrent myocardial infarction (MI). When the study population was stratified by low and high clinical risk (43% vs. 57%, respectively), feelings of being disabled was the most prominent predictor of mortality in the low-risk group (HR=3.5, 95% CI=1.4-8.8).

CONCLUSION

Feelings of being disabled measured at baseline and at 3 months was the most prominent predictor of mortality in low-risk patients 8 years post-MI. This finding adds to the existing knowledge that psychosocial variables influence morbidity and mortality in cardiac patients.

Psychological assessments for cardiac rehabilitation patients

Psychological and quality of life measures are important in the assessment of cardiac rehabilitation (CR) patients and the outcome of treatment. This study aimed to assess the utility and sensitivity to change of three simple questionnaires in a CR setting. A total of 1403 patients who entered CR over 51 months were studied. Patients completed questionnaires before and after their phase 3 CR program-Hospital Anxiety and Depression (HAD) scale, WONCA/COOP charts and an analogue score of wellbeing. The three instruments took about 5.5 min in total to complete and 30 s to interpret. There were highly significant reductions in mean anxiety score-from 6.04 to 4.67 (P<0.001, 95% CI -1.52 to -1.16) and depression from 4.00 to 2.52 (P<0.001, 95% CI -1.62 to -1.29) The mean analogue of wellbeing score improved from 7.09 to 8.19 (P<0.001, 95% CI 0.97-1.22 ) There were highly significant improvements in five of the six WONCA domains. There were significant correlations between improvements in scores from all instruments. The sensitivity indices were in the 'good' range for changes in WONCA physical fitness domain and subjective well-being score and in the (moderate) range for changes in depression, well-being and WONCA overall health. Initial physical fitness was significantly correlated with the initial levels of all psychometric scores except anxiety and WONCA feelings, but improvements in fitness were not correlated with any changes in psychometric scores. The instruments described were quick to administer and to interpret and showed sensitivities to change superior to those which have been reported for other questionnaires. We believe them to be practical tools for use in CR units.

Reducing emotional distress improves prognosis in coronary heart disease: 9-year mortality in a clinical trial of rehabilitation

BACKGROUND

The impact of treating emotional distress on prognosis in coronary heart disease (CHD) has not been documented convincingly. We tested the hypothesis that treatment-related changes in emotional distress may explain the beneficial effect of rehabilitation on prognosis.

METHODS AND RESULTS

In this nonrandomized clinical trial, 150 men with CHD participated in rehabilitation (n=78) or received standard medical care (n=72). There were no differences between rehabilitation and control patients with regard to left ventricular ejection fraction (LVEF) or standard care. End points were reduction in distress after 3 months and mortality after 9 years. At the end of the 3-month trial, 64 patients (43%) reported improvement and 22 (15%) reported deterioration in negative affect. Rehabilitation patients improved more (P=0.004) and deteriorated less (P=0.001) than control patients; rehabilitation was effective in reducing distress. After 9 years of follow-up, 15 patients had died (13 cardiac and 2 cancer deaths). Mortality was associated with LVEF </=50% (P=0.038) and deterioration in negative affect (P=0.007). Rate of death was 17% (12/72) for control patients versus 4% (3/78) for rehabilitation patients (P=0.009); rehabilitation was effective in reducing mortality. LVEF </=50% (OR 3.2; 95% CI 1.1 to 9.8; P=0.041) and rehabilitation (OR 0.2; 95% CI 0.1 to 0.7; P=0.016) were independent predictors of mortality. Rehabilitation warded off the deleterious effect of deterioration in negative affect on prognosis.

CONCLUSIONS

Deterioration in negative affect is associated with a high long-term mortality risk. Warding off deterioration in negative affect is a mechanism that may explain the beneficial effect of comprehensive rehabilitation on prognosis in patients with CHD.

Feelings of being disabled as a predictor of mortality in men 10 years after percutaneous coronary transluminal angioplasty

OBJECTIVE

To examine the independent prognostic value of the four subscales of the Heart Patients Psychological Questionnaire (HPPQ) on mortality in male and female patients 10 years following percutaneous transluminal coronary angioplasty (PTCA).

METHODS

The HPPQ, which measures well-being, feelings of being disabled, despondency, and social inhibition, was administered to 356 patients (23% women) post-PTCA. The patients were followed for a median of 10 years. Clinical and demographic variables were sampled from medical records.

RESULTS

During the follow-up period, 104 patients (29%) had died. Women scored significantly worse on all psychological subscales compared with men. Fifty-nine (72%) women and 92 (34%) men had a score indicating at least mild to moderate feelings of being disabled. Men scoring high on feelings of being disabled were at increased risk of mortality compared with men having a low score, adjusted for other cardiac risk factors (chi(2)=7; P=.008). No differences were found between women with low or high scores on feelings of being disabled (relative risk (RR): 1.2; 95% confidence interval (CI): 0.5-3.3). None of the other HPPQ subscales were related to mortality.

CONCLUSION

Feelings of being disabled measured at least 1 year after hospital discharge is a significant predictor of mortality in men 10 years post-PTCA, but not in women. This finding adds to the increasing knowledge that psychosocial variables influence morbidity and mortality in cardiac patients.

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

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

Comparison of intensive outpatient cardiac rehabilitation to standard outpatient care in veterans: effects on quality of life

BACKGROUND

Examination of the effect of cardiac rehabilitation (CR) on quality of life has been relatively limited. The current study examined existing clinical data, which had been obtained during the course of program evaluation. Changes in quality of life for patients who participated in an intensive rehabilitation program and those who had received standard outpatient care only were compared.

METHODS

Quality-of-life changes in cardiac patients (n = 87) from two treatment groups were compared. Patients had either participated in an 8-week intensive CR program (n = 45) consisting of monitored exercise 3 days weekly and inter-disciplinary education sessions, or routine outpatient clinic services (n = 42).

RESULTS

Patients in the intensive CR program demonstrated significant (P < 0.05-< 0.001) improvement in all areas of quality of life assessed. In contrast, patients that received routine outpatient care did not demonstrate any areas of improvement, while Vitality was significantly (P < 0.05) poorer at posttest.

CONCLUSIONS

Our results suggest that provision of more intensive outpatient CR can improve quality of life more than standard outpatient care.

Differential effects of high-frequency versus low-frequency exercise training in rehabilitation of patients with coronary artery disease

OBJECTIVES

We sought to study the influence of frequency of exercise training during cardiac rehabilitation on functional capacity (i.e., peak oxygen consumption [VO2] and ventilatory anaerobic threshold [VAT]) and quality of life (QoL).

BACKGROUND

Although the value of cardiac rehabilitation is now well established, the influence of the different program characteristics on outcome has received little attention, and the effect of frequency of exercise training is unclear. Functional capacity is regularly evaluated by peak VO2 but parameters of submaximal exercise capacity such as VAT should also be considered because submaximal exercise capacity is especially important in daily living.

METHODS

Patients with coronary artery disease (n = 130, 114 men; mean age 52 +/- 9 years) were randomized to either a high- or low-frequency program of six weeks (10 or 2 exercise sessions per week of 2 h, respectively). Functional capacity and QoL were assessed before and after cardiac rehabilitation. Global costs were also compared.

RESULTS

Compared with baseline, mean exercise capacity increased in both programs: for high- and low-frequency, respectively: peak VO2 = 15% and 12%, Wmax = 18% and 12%, VAT = 35% and 12% (all p < 0.001). However, when the programs were compared, only VAT increased significantly more during the high-frequency program (p = 0.002). During the high-frequency program, QoL increased slightly more, and more individuals improved in subjective physical functioning (p = 0.014). We observed superiority of the high-frequency program, especially in younger patients. Mean costs were estimated at 4,455 and 2,273 Euro, respectively, for the high- and low-frequency programs.

CONCLUSIONS

High-frequency exercise training is more effective in terms of VAT and QoL, but peak VO2 improves equally in both programs. Younger patients seem to benefit more from the high-frequency training.

Cardiac rehabilitation: socially deprived patients are less likely to attend but patients ineligible for thrombolysis are less likely to be invited

OBJECTIVE

To identify factors associated with the uptake of cardiac rehabilitation following acute myocardial infarction.

DESIGN

Retrospective analysis using multivariate logistic regression modelling.

SETTING

Two large teaching hospitals in Nottingham.

PATIENTS

Cohorts of patients admitted with acute myocardial infarction in 1992 and 1996.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Factors in multivariate analysis found to be associated with attendance at cardiac rehabilitation. Use of secondary prevention in those who were and were not invited and those who did and did not attend cardiac rehabilitation.

RESULTS

58% of all patients were offered cardiac rehabilitation. Attendance rates were 60% in 1992 and 74% in 1996. Invitations were more likely to be offered to younger patients, those who had received thrombolysis, and to patients admitted to one of the two Nottingham hospitals. Use of secondary prevention was only 48% in 1992 but this increased to 80% in 1996. Patients not receiving secondary prevention were less likely to be invited to cardiac rehabilitation. Social deprivation was the only factor significantly associated with poor uptake of cardiac rehabilitation in both years. There was no difference in the use of secondary prevention between those who did and did not attend cardiac rehabilitation.

CONCLUSION

Those invited to attend a cardiac rehabilitation programme are likely to be in a good prognosis group, comprising those who are young and have received thrombolysis. Those at greatest risk, particularly patients from socially deprived areas, seem to be missing out on the potential benefits of cardiac rehabilitation. High risk patients should be specifically targeted to ensure that they are invited to, and encouraged to, attend a programme of cardiac rehabilitation.

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

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

Effect of high- versus low-frequency exercise training in multidisciplinary cardiac rehabilitation on health-related quality of life

BACKGROUND

The authors examined the importance of the frequency of aerobic exercise training in multidisciplinary rehabilitation in improving health-related quality of life in the short run in patients with documented coronary artery disease.

METHODS

Patients (114 males and 16 females; age range, 32-70 years) were randomized into either a high-frequency or a low-frequency exercise training program (10 versus 2 sessions per week, respectively) as part of a 6-week multidisciplinary cardiac rehabilitation program. The General Health Questionnaire and the RAND-36 were used to assess changes in psychological distress and subjective health status.

RESULTS

After 6 weeks, high-frequency patients reported significantly more positive, change in "psychological distress" (P < 0.05), "mental health" (P = 0.05), and "health change" (P < 0.01), than low-frequency patients. Apart from changes in mean scores, individual effect sizes indicated that a significantly greater percentage of high-frequency patients experienced substantial improvements in "psychological distress" (P < 0.01), "physical functioning" (P < 0.05), and "health change" (P < 0.05), compared with low-frequency patients. In addition, deterioration of quality of life was observed in a considerable number of high-frequency patients (ranging from 1.7% to 25.8% on the various measures).

CONCLUSIONS

The frequency of aerobic exercise has a positive, independent effect on psychological outcomes after cardiac rehabilitation. However, this benefit after high-frequency rehabilitation appears to be limited to a subgroup of patients. Further investigation is required to identify these patients. Results provide input into recent controversies regarding the role of exercise training in cardiac rehabilitation.

Evidence for the effectiveness of cardiac rehabilitation

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

Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction

BACKGROUND

Patients with myocardial infarction (MI) with a decreased left ventricular ejection fraction (LVEF) have a poor prognosis, but the role of emotional stress in prognosis is not known. We hypothesized that emotional stress in these patients (1) is unrelated to the severity of cardiac disorder, (2) predicts cardiac events, and (3) is a function of basic personality traits.

METHODS AND RESULTS

Eighty-seven patients with MI (age, 41 to 69 years) with an LVEF of < or =50% underwent psychological assessment at baseline. Patients and their families were contacted after 6 to 10 years (mean, 7.9 years); cardiac events were defined as cardiac death or nonfatal MI. Emotional distress was unrelated to the severity of cardiac disorder. At follow-up, 21 patients had experienced a cardiac event (13 fatal events). These events were related to LVEF of < or =30%, poor exercise tolerance, previous MI, anxiety, anger, and depression (all P< or =.02). Patients with a distressed personality (type D; ie, the tendency to suppress negative emotions) were more likely to experience an event over time compared with non-type D patients (P=.00005). Cox proportional hazards analysis yielded LVEF of < or =30% (relative risk, 3.0; 95% confidence interval, 1.2 to 7.7; P=.02) and type D (relative risk, 4.7; 95% confidence interval, 1.9 to 11.8; P=.001) as independent predictors. Anxiety, anger, and depression did not add to the predictive power of type D; these negative emotions were highly correlated and reflected the personality domain of negative affectivity.

CONCLUSIONS

Personality influences the clinical course of patients with a decreased LVEF. Emotional distress in these patients is unrelated to disease severity but reflects individual differences in personality. Clinical trials should take a broad view of the target of intervention; assessment of LVEF and personality may identify patients at risk.

Depression and coronary heart disease: observations and questions

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

Personality as independent predictor of long-term mortality in patients with coronary heart disease

BACKGROUND

Emotional distress has been related to mortality in patients with coronary heart disease (CHD), but little is known about the role of personality in long-term prognosis. We postulated that type-D personality (the tendency to suppress emotional distress) was a predictor of long-term mortality in CHD, independently of established biomedical risk factors.

METHODS

We studied 268 men and 35 women with angiographically documented CHD, aged 31-79 years, who were taking part in an outpatient rehabilitation programme. All patients completed personality questionnaire at entry to the programme. We contacted them 6-10 years later (mean 7-9) to find out survival status. The main endpoint was death from all causes.

FINDINGS

At follow-up, 38 patients had died; there were 24 cardiac deaths. The rate of death was higher for type-D patients than for those without type-D (23 [27%]/85 vs 15 [7%]/218; p < 0.00001). The association between type-D personality and mortality was still evident more than 5 years after the coronary event and was found in both men and women. Mortality was also associated with impaired left ventricular function, three-vessel disease, low exercise tolerance, and the lack of thrombolytic therapy after myocardial infarction. When we controlled for these biomedical predictors in multiple logistic regression analysis, the impact of type-D remained significant (odds ratio 4.1 [95% CI 1.9-8.8]; p = 0.0004). In this group of CHD patients, type-D was an independent predictor of both cardiac and non-cardiac mortality. Social alienation and depression were also related to mortality, but did not add to the predictive power of type-D.

INTERPRETATION

We found that type-D personality was a significant predictor of long-term mortality in patients with established CHD, independently of biomedical risk factors. Personality traits should be taken into account in the association between emotional distress and mortality in CHD.

Personality and mortality after myocardial infarction

Previous research showed: a) emotional distress is a risk factor for mortality after myocardial infarction (MI) and b) emotional distress is linked to stable personality traits. In this study, we examined the role of these personality traits in mortality after MI. Subjects were 105 men, 45 to 60 years of age, who survived a recent MI. Baseline assessment included biomedical and psychosocial risk factors, as well as each patient's personality type. After 2 to 5 (mean, 3.8) years of follow-up, 15 patients (14%) had died. Rate of death for patients with a distressed personality type (11/28 = 39%) was significantly greater than that for patients with other personality types (4/77 = 5%) (p < .0001). Patients with this personality type tend simultaneously to experience distress and inhibit expression of emotions. Low exercise tolerance, previous MI (p < .005), anterior MI, smoking, and age (p < .05) were also associated with mortality. A logistic regression model including these biomedical factors had a sensitivity for mortality of only 27%. The addition of distressed personality type in this model more than doubled its sensitivity. Of note, among patients with poor physical health, those with a distressed personality type had a five-fold mortality risk (p < .005). Consistent with the findings of other investigators, depression (p < .005), life stress, use of benzodiazepines (p < .01), and somatization (p < .05) were also related to post-MI mortality. These psychosocial risk factors were more prevalent in the distressed personality type than in the other personality types (p < .001-.05). Multiple logistic regression indicated that these psychosocial factors did not add to the predictive value of the distressed personality type. Hence, an important personality effect was observed despite the low power. This suggests that personality traits may play a role in the detrimental effect of emotional distress in MI patients.