Psychosocial Aspects in Cardiac Rehabilitation: From Theory to Practice. A Position Paper From the Cardiac Rehabilitation Section of The European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology

Abstract

A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, Type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQL) and prognosis in patients with established CHD.PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews.Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQOL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counseling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counseling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team. Word count of abstract: 246

2016 European Guidelines on cardiovascular disease prevention in clinical practice

“…99,100 Clinical depression and depressive symptoms predict incident CAD (RR 1.6 and 1.9, respectively) 101 and worsen its prognosis (RR 1.6 and 2.4, respectively). 92,96,101,102 Vital exhaustion, most likely representing somatic symptoms of depression, significantly contributed to incident CAD (population attributable risk 21.1% in women and 27.7% in men). The NRI improved significantly.…”

“…103 Panic attacks also increase the risk of incident CAD (RR 4.2). 104 Anxiety is an independent risk factor for incident CAD (RR 1.3), 92 for cardiac mortality following AMI [odds ratio (OR) 1.2] 105 and cardiac events (OR 1.7). 106 Meta-analyses reported a 1.5-fold risk of CVD incidence, a 1.2-fold risk of CAD and 1.7-fold risk for stroke in patients with schizophrenia, 107 and a 1.3-fold risk for incident CAD, even after adjustment for depression, in patients with posttraumatic stress disorder.…”

Perceptions of illness as predictive factors for perceived stress in patients participating in a cardiac rehabilitation program

“…Psychological factors have been identified as an important predictor for program adherence (Alavi et al, ; Sarrafzadegan et al, ). Patients with CVD often experience stress (Dimsdale, ), which not only has a negative effect on their health and well‐being (Brummett et al, ) but also acts as a barrier to lifestyle change (Pogosova et al, ). Percieved stress could inhibit adherence to prescribed treatment interventions in CVD patients (Qi, ).…”

An assessment of decision to change lifestyle in cardiovascular patients after hospitalization

“…In assessing the lifestyle before hospitalization, the highest degree of agreement occured with the statements "I was often tense, angry or worried about the events in society" and "I was often tense, angry or worried while following the media". These findings can be seen in the context of numerous studies in which psychosocial risk factors for cardiovascular disease development have shown that people who tend to experience negative affective states and poor mood are generally prone to develop cardiovascular disease (8,9,11,12). Negative emotions act as stressors.…”