Cognitive-behavioural therapy reduces psychological distress in younger patients with cardiac disease: a randomized trial.

AIMS: To test whether usual outpatient cardiac rehabilitation (CR) supplemented by a cognitive-behavioural therapy (CBT) intervention may reduce anxiety and depression compared with usual CR. METHODS AND RESULTS: In this multicentre randomized controlled trial, 147 cardiac patients (67% men, mean age 54 years, 92% with coronary artery disease) with psychological distress defined as a hospital anxiety and depression scale (HADS) anxiety or depression score ≥8 were randomized to five sessions of group CBT plus usual CR (intervention, n = 74) or CR alone (control, n = 73). Patients with severe distress or a psychiatric diagnosis were excluded. The intervention was delivered by cardiac nurses with CBT training and supervised by a psychologist. A reference, non-randomized group (background, n = 41) of consecutive patients without psychological distress receiving usual CR was included to explore the effect of time on HADS score. The primary outcome, total HADS score after 3 months, improved more in the intervention than in the control group [the mean total HADS score improved by 8.0 (standard deviation 5.6) vs. 4.1 (standard deviation 7.8), P < 0.001]. Significant between-group differences were maintained after 6 months. Compared with the control group, the intervention group also had greater adherence to CR (P = 0.003), more improvement in the heart-related quality of life (HeartQoL) at 6 months (P < 0.01), and a significant reduction in cardiac readmissions at 12 months (P < 0.01). The background group had no significant change in HADS score over time. CONCLUSION: Brief CBT provided by cardiac nurses in relation to CR reduced anxiety and depression scores, improved HeartQoL and adherence to CR, and reduced cardiovascular readmissions. The programme is simple and may be implemented by CR nurses.

The motivation for physical activity is a predictor of VO2peak and is a useful parameter when determining the need for cardiac rehabilitation in an elderly cardiac population.

BACKGROUND: Exercise-based cardiac rehabilitation (CR) is an essential contributor to a successful recovery for elderly cardiac patients. The motivation for physical activity is a psychological parameter seldom described in secondary prevention, and it is plausible that motivation contributes to the differential effect of CR. PURPOSE: To investigate if motivation, measured using the behavioural regulation in an exercise questionnaire (BREQ-2), predicts VO2peak in elderly cardiac patients before and after CR. METHODS: A prospective cohort study of elderly ischemic cardiac patients and patients with valvular disease participating in cardiac rehabilitation was used. Motivation was measured using BREQ-2, which measures five constructs of motivation and a summed score-the relative autonomy index (RAI). VO2peak was measured before and after CR using a cardiopulmonary exercise test (CPET). RESULTS: Two hundred and three patients performed the baseline tests and initiated CR. One hundred and eighty-two completed CR and comprised the follow-up group. The mean VO2peak was 18 ml/kg/min (SD±5.1). VO2peak increased significantly with increasing motivation, 1.02 (.41-1.62) ml/kg/min pr. SD. Mean improvement from CR was 2.3 ml/kg/min (SD±4.3), the equivalent of a 12% increase. A change in VO2peak after CR was likewise positively associated with increased motivation, .74 (.31-1.17) pr. SD. CONCLUSION: The level of motivation predicts VO2peak before CR, and is also able to predict changes in VO2peak following CR. Motivation measured with the BREQ-2 questionnaire can be applied as a screening tool for elderly cardiac patients before they initiate CR to identify patients with need of specific attention.

Intensive group-based cognitive therapy in patients with cardiac disease and psychological distress-a randomized controlled trial protocol.

BACKGROUND: Many patients with coronary artery disease (CAD) and valvular heart disease (VHD) suffer from psychological distress. Such stress is associated with increased morbidity, reduced quality of life and delayed return to work. European guidelines emphasize recognition and intervention, but evidence-based treatment options are limited and perceived as costly. The present study will test the effect of brief, group-based cognitive therapy as an adjunct to usual cardiac rehabilitation in a randomized design. METHODS: A total of 148 patients with CAD and/or VHD after surgical intervention and concomitant psychological distress (defined as HADS anxiety (A) or depression (D) score ≥8) will be randomized to either usual out-patient cardiac rehabilitation (CR) comprising an 8-week multidisciplinary programme or usual care supplemented by five group-based cognitive therapy sessions performed by trained CR nurses. A structured, standardized treatment manual will be used. Patients will be randomized 1:1 at three different sites. Additionally, a non-randomized sub-group of 40 matched patients without signs of psychological distress will be followed to investigate spontaneous variation in HADS. The primary outcome is Hospital Anxiety and Depression Score (HADS). Secondary outcomes are adherence to cardiac rehabilitation (CR), health-related quality of life measured by HeartQoL, time to return to work, adherence to lifestyle interventions and cardiovascular readmissions. Patients are followed up for 12 months. DISCUSSION: To our knowledge, this is the first randomized controlled trial (RCT) on patients with cardiac disease with an intensive group-based programme of cognitive therapy performed by CR nurses, which makes it affordable and widely implementable. The outcome will elucidate the feasibility and effect of cognitive therapy as an adjunct to CR in patients with post-surgery CAD and/or VHD and psychological distress and could possibly benefit patients with other heart conditions as well. The clinical trial complies with the Declaration of Helsinki. The trial has been approved by The Regional Research Ethics Committee (file number H-16042832) and The Danish Data Protection Agency. The results will be disseminated as original research in peer-reviewed manuscripts. TRIAL REGISTRATION: www.clinicaltrials.gov NCT04254315 . Retrospectively registered on 30 January 2020.

Cardiac rehabilitation of elderly patients in eight rehabilitation units in western Europe: Outcome data from the EU-CaRE multi-centre observational study.

AIMS: The European Cardiac Rehabilitation in the Elderly (EU-CaRE) HORIZON 2020 project compares the sustainable effects of cardiac rehabilitation (CR) in elderly patients. METHODS AND RESULTS: A total of 1633 patients with coronary artery disease (CAD) or heart valve replacement (HVR), with or without revascularization, aged 65 or above, who participated in CR were included. Peak oxygen uptake (VO2peak), smoking, body mass index, diet, physical activity, serum lipids, psychological distress and medication were assessed before and after CR (T0 and T1) and after 12 months (T2). Patients undergoing coronary artery bypass surgery or surgical HVR had lower VO2peak at T0 and a greater increase to T1 and T2 (2.8 and 4.4 ml/kg/min, respectively) than CAD patients undergoing percutaneous or no revascularization (1.6 and 1.4 ml/kg/min, respectively). After multivariable adjustment, earlier CR uptake was associated with greater improvements in VO2peak. The proportion of CAD patients with three or more uncontrolled risk factors declined from 58.4% at T0 to 40.1% at T2 (p < 0.0001). Psychological distress scores all improved and adherence to medication was overall good at all sites. There were significant differences in risk factor burden across sites, but no CR program was superior to others. CONCLUSIONS: The outcomes of VO2peak in CR programs across Europe seemed mainly determined by timing of uptake and were maintained or even further improved at 1-year follow-up. Despite significant improvements, 40.1% of CAD patients still had three or more risk factors not at target after 1 year. Differences across sites could not be ascribed to characteristics of the CR programs offered.

Cardiac rehabilitation in the elderly patient in eight rehabilitation units in Western Europe: Baseline data from the EU-CaRE multicentre observational study.

BACKGROUND: Due to the progressive deconditioning, comorbidities and higher complication rates, elderly patients are in particular need of cardiac rehabilitation. We compared elderly patients (65+ years old) participating in cardiac rehabilitation, focusing on baseline characteristics, risk factor control and functional assessment. METHODS: The EU-CaRE study is a prospective study comparing cardiac rehabilitation in eight centres across Western Europe. Consecutive patients with acute coronary syndrome, stable coronary artery disease and heart valve replacement undergoing cardiac rehabilitation were included. RESULTS: Of 1633 patients (median age 72 years) participating, 54% had acute coronary syndrome, 33% had stable coronary artery disease and 13% followed valve replacement. Fifty-five per cent had undergone percutaneous coronary intervention and 29% coronary artery bypass grafting. Characteristics varied across centres: 23% (17-27%) were women, 4% (0-12%) were of non-European origin and 16% (4-32%) were living alone. Median time from index event to start of cardiac rehabilitation varied from 11 to 49 days (p < 0.001). Mean VO2peak was relatively low (16 mL/kg per min) and varied significantly between the participating centres, largely unaffected by multivariable adjustment. Overall patients received guideline recommended treatment: 93% (87-97%) were on a statin and 70% (55-85%) an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. However, risk factor control was inadequate: 58% had three or more risk factors not controlled. CONCLUSION: EU-CaRE provides a snapshot of the elderly population with heart disease participating in cardiac rehabilitation across countries in Western Europe. Risk factors and exercise capacity indicate the continued need for cardiac rehabilitation in these patients. Of concern, the lag-time to start of cardiac rehabilitation needs improvement in many centres.

Depression, Socioeconomic Factors, and Ethnicity as Predictors of Cardiorespiratory Fitness Before and After Cardiac Rehabilitation.

PURPOSE: To determine whether cardiac patients with psychosocial or socioeconomic problems have lower peak oxygen uptake ((Equation is included in full-text article.)O2peak) and whether these factors modify the effect of cardiac rehabilitation (CR). METHODS: A retrospective cohort study of patients with ischemic heart disease, valvular heart disease, or heart failure referred for CR. (Equation is included in full-text article.)O2peak was assessed by a maximal cardiopulmonary exercise test. Pre-existing depression was defined by use of antidepressants and new-onset depression by a modified Primary Care Evaluation of Mental Disorders (PRIME-MD) questionnaire at CR intake. Socioeconomic status was defined by educational attainment and working status; ethnicity as Western European or non-Western European. Full data from baseline assessment were available on 1217 patients and follow-up on 861 patients. RESULTS: Mean ± SD (Equation is included in full-text article.)O2peak before CR was 21.8 ± 6.8 mL/kg/min. After multivariable adjustment, lower (Equation is included in full-text article.)O2peak was associated with lower educational attainment, not working, and non-Western ethnicity but not with depression. Mean improvement of (Equation is included in full-text article.)O2peak following CR was 2.4 ± 4.3 mL/kg/min. After multivariable adjustment educational attainment, employment status and ethnicity were significant predictors of improvement of (Equation is included in full-text article.)O2peak while depression was not. CONCLUSION: Education, attachment to the workforce, and ethnicity were all associated with lower (Equation is included in full-text article.)O2peak before CR, and the disparity was increased following CR. Having pre-existing depression and new-onset depression did not influence (Equation is included in full-text article.)O2peak either before or after CR. These results point to important subgroups in need of specially-tailored rehabilitation programs.