Reducing Emotional Distress Improves Prognosis in Coronary Heart Disease

Abstract

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 (nϭ78) or received standard medical care (nϭ72). 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 (Pϭ0.004) and deteriorated less (Pϭ0.001) 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 Յ50% (Pϭ0.038) and deterioration in negative affect (Pϭ0.007). Rate of death was 17% (12/72) for control patients versus 4% (3/78) for rehabilitation patients (Pϭ0.009); rehabilitation was effective in reducing mortality. LVEF Յ50% (OR 3.2; 95% CI 1.1 to 9.8; Pϭ0.041) and rehabilitation (OR 0.2; 95% CI 0.1 to 0.7; Pϭ0.016) 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.

A mechanism converting psychosocial stress into mononuclear cell activation

“…The consistent results obtained in healthy volunteers, animal studies, and studies in vitro provide strong evidence that the mechanism described is not only observed in a single model, but may be applicable to rather different situations with increased NA release as the common denominator. However, it remains unknown whether the changes induced by a brief psychosocial stressor are indeed sufficient to explain the relation of psychosocial stress to cardiovascular disease (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15). It is more likely that a repeated exposure to adverse, i.e., stressful, life events with failure to habituate biologically to these circumstances will convey the well documented disease outcomes (56).…”

“…In chronic diseases, in which these RAGE ligands are abundantly expressed, psychosocial stress-induced NF-B activation might not only be amplified, but converted to a constant threat (25,57). Clinical and experimental studies provide evidence that lowering psychosocial stress by ␤-adrenergic inhibitors (9,11,12) and͞or stress management (13)(14)(15)(16) lead to reduction of the intima media thickness (13) and the overall cardiovascular mortality (14,15).…”

“…Intervention studies in cynomolgus monkeys support this concept, showing not only activation of these processes by mental stress but also reduction of vascular dysfunction and disease by reducing psychosocial stress through ␤-adrenergic blockade (8)(9)(10)(11)(12). Consistently, behavioral interventions, stress reduction, and stress management demonstrated benefits over and above usual medical care in hypertensive African Americans (13) and in cardiac patients with evidence of myocardial ischemia (14)(15)(16)(17)(18).…”

Impact of depression on sexual dysfunction and HRQoL in CAD patients

“…According to BDI score range, patients were divided into 4 groups: minimal (0-13), mild (14)(15)(16)(17)(18)(19), moderate (20)(21)(22)(23)(24)(25)(26)(27)(28) and severe depression (29-63) groups. …”

“…Rehabilitation programs that are successful in reducing emotional distress may be more successful in reducing mortality than programs without a psychological component. Reduction in distress might modify pathophysiological mechanisms that have been associated with stress-related cardiac events, and intervention should be effective in reducing distress and tailored to the needs of each patient [24].…”