New Orleans, LA - In addition to improving traditional cardiac risk factors such as lipid levels, obesity, and exercise capacity, undergoing a cardiac rehabilitation program after a cardiac event also markedly improves psychological factors such as depression, anxiety, and hostility, a new study shows [1].

The study, published in the September 25, 2006 issue of the Archives of Internal Medicine, also found that, contrary to the general view, younger patients actually seemed to gain the most from a cardiac rehabilitation program, which consists of group exercise sessions and classes giving advice and reassurance, particularly in terms of psychological risk factors.

Lead author Dr Carl Lavie (Ochsner Medical Center, New Orleans, LA), told heartwire that many studies have shown that psychological distress is an important cardiovascular risk factor, but this does not tend to be emphasized or well recognized among physicians, especially cardiologists. "In our study, a simple 12-week program of exercise and advice sessions had dramatic benefits on both cardiovascular and psychological factors. Cardiologists on the whole like to do high-tech things—implant stents and balloons and use state-of-the-art medication, but they can often overlook the fact that a simple cardiac rehabilitation program can actually have massive benefits."

Lavie also pointed out that while many may believe that such programs are best directed at elderly patients who are obviously more debilitated than younger patients, they have shown for the first time that these programs are just as important, if not more so, for younger patients. They found that younger patients with heart disease actually had a worse risk profile than older patients, with more obesity, worse lipid profiles, and a lot more anxiety and hostility. And there were dramatic improvements in these parameters after the rehabilitation program, with a 50% to 80% reduction in anxiety, hostility, and depression.

In the study, the researchers assessed behavioral data, quality of life, and risk profiles in 635 consecutive patients before and after cardiac rehabilitation and exercise training and specifically assessed data in 104 young patients (mean age 48) compared with 260 elderly patients (mean age 75). Patients generally started the program about a month after a major cardiovascular event such as an MI or ACS or a CABG procedure. The program consisted of three sessions a week of exercise and educational classes encouraging healthy lifestyles and additional exercising at home for 12 weeks. Lavie commented to heartwire that these sessions included discussion about psychological adaptation but not on an individualized basis. "The patients got a lot of TLC, but there was no individual counseling."

Results showed that compared with older patients, young patients had higher body-mass indexes, worse cholesterol profiles, and higher scores for anxiety, hostility, and depression compared with elderly patients. Following cardiac rehabilitation and exercise training, all patients showed benefits to their risk profiles, but these were particularly pronounced in the younger group. Young patients also had >50% to >80% reductions in the prevalence of anxiety, hostility, and depression.

Lavie commented: "The message from this study is that young patients benefit enormously from cardiac rehabilitation programs, and we need to do more to encourage them to attend." He said that younger patients often don't attend such programs, probably because they are eager to return to work and have less time than older patients and also, because they generally have better exercise capacity than older patients, cardiologists may think younger patients do not need such programs. "But we have actually shown the opposite—that younger patients seem to benefit even more—and a large part of this is in reducing psychological factors, and we know that stress and depression are not good for your heart."

This may not be the fanciest study, but it is a study that people can relate to.

He added that he did not know which part of the program was responsible for the benefits shown, but exercise probably played a big part. "Even if patients do not attend these programs, cardiologists must stress the importance of exercise to them. But attending sessions with other patients and receiving structured advice probably also helped. After a cardiac event, patients are often frightened of exercising, and these programs can help reassure them. Our study supports the view that exercise brings dramatic benefits in psychological health in general, not just in heart-disease patients. This may not be the fanciest study, but it is a study that people can relate to."

Lavie estimated that only about 5% to 10% of cardiac patients actually attend cardiac rehabilitation. "Many centers do not have a program, and even in our hospital, where we are very interested in this, there is only a 25% to 30% attendance rate. More should be done by the referring cardiologist to emphasize the benefits of such programs to patients, and patients from hospitals without such a program can always attend one in a different center."

Another study published recently highlights the problem of depression in heart-failure patients. Writing in a paper published online September 26, 2006 in the Journal of the American College of Cardiology, a group led by Dr Thomas Rutledge (VA San Diego Health Care System, CA) reports a review of the literature, which shows a "moderate to high prevalence of depression among patients with heart failure and an increased risk of mortality and clinical events among heart-failure patients with depressive symptoms."

They point out that the relationship between depression and heart failure is a relatively new but rapidly expanding area of interest in cardiology research, coinciding with the growth in heart failure as a healthcare problem. They conducted a quantitative review of the literature on depression and heart failure concerning questions about depression prevalence, clinical outcomes, and treatment impact. Results showed that depression is common among patients with heart failure, with approximately one in five patients meeting criteria for major depression based on interview methods, and substantially higher rates of clinically significant depression are present among patients assessed with questionnaires or with more severe heart failure. They also found that rates of mortality, clinical events, rehospitalization, and general healthcare use are markedly higher among heart-failure patients reporting more severe depression.

The authors also report that data from existing studies are suggestive of a higher risk of heart-failure development among those with more severe depressive symptoms, as well as higher costs resulting from an increased use of healthcare services, but more data are needed in these areas.

They note that very little information is available on the influence of treating depression in heart-failure patients, but that it would be expected that this would show benefits. They point out that heart failure and depression share several biological mechanisms—both are associated with sympathetic activation and elevated proinflammatory cytokines—and that the additive effects of the inflammation found in depression likely adversely affect the heart. In the few studies published of antidepressant treatment in heart failure, patients have shown a general pattern of decreased depressive symptoms and increased physical abilities, but more studies are needed in this area, they conclude.