Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Adverse Psychological and Coronary Risk Profiles in Young Patients With Coronary Artery Disease and Benefits of Formal Cardiac Rehabilitation

Adverse Psychological and Coronary Risk Profiles in Young Patients With Coronary Artery Disease... BackgroundRecent data indicate that young patients with coronary artery disease (CAD) have a poor long-term prognosis. Although the benefits of formal cardiac rehabilitation and exercise training programs are well established, most of these data come from middle-aged and older patients.MethodsWe assessed baseline behavioral data, quality of life, and risk profiles in 635 consecutive patients with CAD before and after cardiac rehabilitation and exercise training, and specifically assessed data in 104 young patients (mean ± SD age, 48 ± 6 years; range, 22-54 years) compared with 260 elderly patients (mean ± SD age, 75 ± 3 years; range, 70-85 years).ResultsCompared with older patients, young patients had higher body mass indexes (12.2%, P<.001), total cholesterol–high-density lipoprotein ratio (14.6%, P<.01), and triglycerides level (27.2%, P<.01), and a lower high-density lipoprotein cholesterol level (−8.8%, P=.045). Young patients also had higher scores for anxiety and hostility (51.5% and 94.4%, respectively; P<.001 for both), a considerably higher prevalence of anxiety (27.9% vs 13.5%; P<.01) and hostility (12.5% vs 4.6%; P<.01) symptoms, and slightly more depression symptoms (23.1% vs 18.8%) compared with elderly patients. Following cardiac rehabilitation and exercise training, young patients had improvements in body mass index (−1.7%, P<.01), percentage body fat (−4.4%, P<.001), high-density lipoprotein cholesterol level (10.2%, P<.001), high-sensitivity C-reactive protein level (−33.3%, P<.01), peak oxygen consumption (11.3%, P<.001), resting heart rate (−4.5%, P=.01), and resting systolic pressure (−2.3%, P=.049), and marked improvements in scores for depression (−58.5%), anxiety (−46.0%), hostility (−45.7%), somatization (−33.8%), and quality of life (15.8%) (P<.001 for all). Young patients also had greater than 50% to greater than 80% reductions in the prevalence of anxiety (P<.001), hostility (P<.01), and depression (P<.001).ConclusionThese data demonstrate the adverse psychological and CAD risk profiles that are present in young patients with CAD following major CAD events, and are consistent with substantial benefit of formal cardiac rehabilitation and exercise training programs in younger adults.Substantial evidence indicates that psychological distress is a significant coronary artery disease (CAD) risk factor and adversely affects recovery after major CAD events.Although most of this evidence has focused on the high prevalence of depression in patients with CAD and on depression as a CAD risk factor,evidence also indicates that anxiety and hostility are associated with an increase in CAD events.A psychosocial index comprising many of these behaviors has recently been shown to be an independent risk factor for the development of myocardial infarction.Moreover, these psychological risk factors have been associated with dyslipidemia, hypertension, obesity, inflammatory biomarkers, coronary calcium and atherosclerosis, and peripheral atherosclerosis.Although elderly persons compose the largest portion of patients with CAD, recent studiessuggest that younger patients represent a growing segment of the population with CAD and carry a poor long-term prognosis. Researchershave demonstrated the marked benefits of cardiac rehabilitation and exercise training (CRET) programs in secondary CAD prevention, including benefits on standard CAD risk factors and psychological factors; however, most of these studies have been performed in middle-aged and older subjects.The present study determines the baseline psychological and overall CAD risk profiles in many younger patients with CAD and compares them with those of older patients, following a CAD event. We also sought to document the effects of formal phase 2 CRET programs in this young cohort with CAD.METHODSSTUDY POPULATIONWe studied 635 consecutive patients with CAD who were referred to, attended, and completed phase 2 CRET programs at Ochsner Clinic Foundation in New Orleans, following major CAD events (myocardial infarction, unstable angina, or major coronary revascularization), and we specifically assessed detailed data in 104 young patients with CAD (aged <55 years; mean ± SD age, 48 ± 6 years; age range, 22-54 years; 73.1% male) compared with 260 elderly patients (aged ≥70 years; mean ± SD age, 75 ± 3 years; age range, 70-85 years; 75.4% male). We also report baseline data in 52 young patients (aged <55 years; mean ± SD age, 48 ± 5 years; age range, 23-54 years; 76.9% male) and 68 older patients (aged ≥70 years; mean ± SD age, 76 ± 4 years; age range, 70-88 years; 67.2% male) who either enrolled and did not attend formal CRET or dropped out during the program. All patients completed validated questionnaires before and after the CRET program. This study was approved by the institutional review board of Ochsner Clinic Foundation.BEHAVIORAL TESTINGThe Kellner Symptom Questionnaire has been validated to assess behavioral characteristics, including symptoms of depression, anxiety, hostility, and somatization, with a lower score indicating a more favorable behavioral trait (manual of the symptom questionnaire available on request; R. P. Kellner, MD, PhD, written and oral communication, 1986).The Medical Outcomes Study 36-Item Short-Form Health Survey was used to assess the total quality-of-life score using a standardized coding algorithm, with a higher score indicating a more favorable quality of life.Based on prior studies of mean scores in healthy subjects (R. P. Kellner, MD, PhD, unpublished data, January 1987, normal scores (scaled score between 1 and 2 SDs above the mean) for anxiety and hostility are 7 or less; and for depression, less than 7. Therefore, we chose 8 or higher as a cutoff to indicate anxiety and hostility symptoms and 7 or higher for depression symptoms. In addition, we assessed the prevalence of these behavioral symptoms in the younger vs the older patients.PROTOCOLThe protocol, data collection, and statistical analyses were performed as described previously.The CRET program generally lasted 12 weeks and consisted of 36 educational and exercise sessions, with exercise sessions consisting of 10 minutes of warm-up, calisthenics, and stretching, followed by 30 to 45 minutes of continuous aerobic and dynamic exercise and light isometrics, and approximately 5 to 10 minutes of cooldown. Exercise intensity was prescribed close to the anaerobic or ventilatory threshold obtained by baseline cardiopulmonary stress testing and 10 to 15 beats/min below the level of any exercise-induced or silent myocardial ischemia. In addition, we encouraged patients to perform 1 to 3 exercise sessions per week at home and periodically adjusted exercise prescription to encourage a gradual improvement in overall exercise performance. Besides the exercise portion of the program, daily lectures and group sessions were directed by a licensed nurse, an exercise physiologist, or a dietitian, emphasizing all aspects of CAD and prevention. Although patients and their significant others were taught about behavioral factors, stress, and sexual function and could ask questions in all of these areas, we did not routinely provide individual attention to these areas, including individual counseling directed at high-risk patients with adverse behavioral characteristics, including anxiety, hostility or anger management, and depression.At baseline (2-6 weeks after the major CAD event) and again 1 week after the CRET, we obtained several measurements, including height, weight, body mass index, percentage body fat (by the sum of the skinfold method), fasting plasma lipids level, and cardiopulmonary exercise data.STATISTICAL ANALYSESContinuous variables were expressed as mean ± SD. Two-sample ttests and analysis of variance were used to assess differences in baseline characteristics and CRET data between young and older patients, and baseline characteristics were also compared between those completing and those not completing the CRET program. Changes between baseline and post-CRET data were compared using a paired ttest and &khgr;2analysis, with P<.05 used to determine statistical significance. All data analyses were performed with computer software (StatView; SAS Institute Inc, Cary, NC) on a computer system (Macintosh II; Apple Computers, Inc, Cupertino, Calif).RESULTSThe baseline characteristics of the study cohort are demonstrated in Table 1. Young CRET patients comprised 16.4% of patients completing the formal program and had a significantly higher body mass index (12.2%), total cholesterol–high-density lipoprotein cholesterol ratio (14.6%), and triglycerides level (27.2%), and lower levels of high-density lipoprotein cholesterol (−8.8%) and resting systolic blood pressure (−7.1%), than elderly patients. As expected, young patients had considerably higher levels of peak oxygen consumption (&Vdot;O2) (45.7%). In addition, young patients had higher scores for depression (24.2%), hostility (94.4%), and anxiety (51.5%) than did elderly patients and a slightly higher prevalence of depression symptoms and a significantly higher prevalence of anxiety and hostility symptoms (P<.01 for both) than did older patients (Figure). Although many of the baseline characteristics of young patients not completing CRET were slightly more adverse than the characteristics of those completing CRET, only the difference in peak &Vdot;O2was statistically significant (P=.038). Likewise, elderly patients not completing CRET had significantly lower peak &Vdot;O2and higher anxiety scores (P=.042 for both) compared with elderly patients completing CRET.Figure.Prevalence of adverse behavioral characteristics in young (mean ± SD age, 48 ± 6 years) and elderly (mean ± SD age, 75 ± 3 years) patients with coronary artery disease at baseline. The asterisk indicates P<.01.Table 1. Baseline Characteristics of Young and Older Patients With Coronary Artery Disease, Completing and Not Completing Formal Cardiac RehabilitationCharacteristicYoung Completers(n = 104)Young Noncompleters(n = 52)Elderly Completers(n = 260)Elderly Noncompleters(n = 68)PValue*Total cholesterol level, mg/dL168 ± 42178 ± 36168 ± 34170 ± 35.90Triglycerides level, mg/dL173 ± 132186 ± 122136 ± 63159 ± 114<.01High-density lipoprotein cholesterol level, mg/dL39.4 ± 13.238.4 ± 13.843.2 ± 14.042.6 ± 13.2.045Low-density lipoprotein cholesterol level, mg/dL99 ± 29106 ± 5197 ± 2796 ± 26.71Total cholesterol–high-density lipoprotein cholesterol ratio4.7 ± 1.74.6 ± 1.84.1 ± 1.14.0 ± 1.3<.01Body mass index†30.3 ± 5.930.2 ± 6.127.0 ± 4.527.9 ± 4.9<.001Body fat, %29.3 ± 7.029.1 ± 7.628.3 ± 8.128.5 ± 9.0.30Fasting blood glucose level, mg/dL104 ± 25106 ± 26108 ± 21106 ± 24.25High-sensitivity C-reactive protein level, mg/dL4.2 ± 5.46.4 ± 11.45.6 ± 8.17.5 ± 9.5.12Resting blood pressure, mm Hg Systolic130 ± 16132 ± 18140 ± 20141 ± 21<.001 Diastolic76 ± 1377 ± 1474 ± 1376 ± 14.17Peak oxygen consumption, mL/kg per min20.4 ± 5.317.9 ± 5.3‡14.0 ± 3.312.7 ± 3.3‡<.001Depression score, U4.1 ± 4.85.6 ± 5.93.3 ± 3.74.0 ± 4.1.09Hostility score, U3.5 ± 4.74.4 ± 5.21.8 ± 2.72.1 ± 3.0<.001Anxiety score, U5.0 ± 5.46.1 ± 5.13.3 ± 3.84.6 ± 5.2‡<.001Somatization score, U7.4 ± 4.58.9 ± 5.26.9 ± 3.67.3 ± 4.4.25Total quality-of-life score, U101 ± 2195 ± 2299 ± 1993 ± 16.36 SI conversion factors: To convert high-density lipoprotein, low-density lipoprotein, and total cholesterol to millimoles per liter, multiply by 0.0259; to convert glucose to millimoles per liter, multiply by 0.0555; and to convert triglycerides to millimoles per liter, multiply by 0.0113. *Comparison of young and elderly patients who completed rehabilitation. †Calculated as weight in kilograms divided by the square of height in meters. ‡P<.05 compared with completers.Following the CRET programs (Table 2), the young patients had significant improvements in many variables, including obesity indexes, high-density lipoprotein level, high-sensitivity C-reactive protein level, peak &Vdot;O2, resting heart rate, and resting systolic pressure. In addition, young patients had marked improvements in scores for anxiety, depression, hostility, somatization, and quality of life.Table 2. Risk Factor Changes Noted in 104 Young Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*Risk FactorBefore RehabilitationAfter Rehabilitation% ChangePValueBody mass index†30.3 ± 5.929.8 ± 5.7−1.7<.01Body fat, %29.3 ± 7.028.0 ± 7.8−4.4<.001High-density lipoprotein cholesterol level, mg/dL39.4 ± 13.243.4 ± 12.410.2<.001High-sensitivity C-reactive protein level, mg/dL4.2 ± 5.42.8 ± 3.1−33.3<.01Fasting glucose level, mg/dL104 ± 25101 ± 19−2.9.15Peak oxygen consumption, mL/kg per min20.4 ± 5.322.7 ± 6.111.3<.001Resting heart rate, beats/min66 ± 1163 ± 10−4.5.01Resting systolic blood pressure, mm Hg130 ± 16127 ± 17−2.3.049Anxiety, U5.0 ± 5.42.7 ± 3.7−46.0<.001Depression, U4.1 ± 4.81.7 ± 2.9−58.5<.001Hostility, U3.5 ± 4.71.9 ± 3.3−45.7<.001Somatization, U7.4 ± 4.54.9 ± 3.9−33.8<.001Total quality of life, U101 ± 21117 ± 1815.8<.001 SI conversion factors: See Table 1. *There were no significant changes in the other variables studied in young or older patients, including total cholesterol level, triglycerides level, low-density lipoprotein cholesterol level, and resting diastolic blood pressure. †Calculated as weight in kilograms divided by the square of height in meters.Likewise, elderly patients completing CRET also demonstrated significant improvements in most variables studied (Table 3). Although most of the relative improvements following CRET were statistically similar in the younger and older patients, the young patients had significantly greater improvements in body mass index (−1.7% vs −0.4%; P=.03) and hostility score (−45.7% vs −16.7%; P=.05) and a trend for greater improvement in peak &Vdot;O2(11.3% vs 7.1%; P=.09) compared with the elderly patients. Fasting glucose level decreased minimally following CRET in younger patients and increased significantly in older patients; these relative differences were also statistically significant (P = .03).Table 3. Risk Factor Changes Noted in 260 Older Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*Risk FactorBefore RehabilitationAfter Rehabilitation% ChangePValueBody mass index†27.0 ± 4.526.9 ± 4.1−0.4.65Body fat, %28.3 ± 8.127.1 ± 6.9−4.2<.001High-density lipoprotein cholesterol level, mg/dL43.2 ± 14.045.1 ± 14.24.4<.001High-sensitivity C-reactive protein level, mg/dL5.6 ± 8.13.8 ± 5.0−32.1<.01Fasting glucose level, mg/dL108 ± 21119 ± 4010.2.02Peak oxygen consumption, mL/kg per min14.0 ± 3.315.0 ± 3.67.1<.001Resting heart rate, beats/min65 ± 861 ± 7−6.2<.001Resting systolic blood pressure, mm Hg140 ± 20138 ± 18−1.4.10Anxiety, U3.3 ± 3.82.1 ± 3.0−36.4<.001Depression, U3.3 ± 3.71.9 ± 2.8−42.4<.001Hostility, U1.8 ± 2.71.5 ± 2.4−16.7<.01Somatization, U6.9 ± 3.65.3 ± 4.5−23.2<.001Total quality of life, U99 ± 19112 ± 1713.1<.001 SI conversion factors: See Table 1.*There were no significant changes in the other variables studied in older or younger patients, including total cholesterol level, triglycerides level, low-density lipoprotein cholesterol level, and resting diastolic blood pressure. †Calculated as weight in kilograms divided by the square of height in meters.Following CRET, there was a marked decrease in the prevalence of anxiety symptoms (P<.001), with the prevalence of anxiety being equal after CRET in younger and older patients (Table 4). Likewise, the young patients had a greater than 50% decrease in the prevalence of hostility symptoms and a greater than 80% decrease in depression symptoms following CRET.Table 4. Effects of Cardiac Rehabilitation and Exercise Training Programs on Symptoms of Anxiety, Hostility,and Depression in Young and Older Patients With Coronary Artery DiseaseSymptomYoung Patients (n = 104)Older Patients (n = 260)Before Rehabilitation, %After Rehabilitation, %PValueBefore Rehabilitation, %After Rehabilitation, %PValueAnxiety27.98.7<.00113.59.2<.01Hostility12.55.8<.014.62.3<.05Depression23.13.8<.00118.86.2<.001COMMENTThere are 3 important findings from this investigation. First, young patients compose a significant segment of the population with CAD completing formal CRET programs. Second, young patients with CAD are characterized by a higher degree of psychological distress, obesity, and dyslipidemia. Third, these adverse characteristics substantially improved following formal phase 2 CRET programs.The importance of behavioral and psychological risk factors in the pathogenesis and expression of atherosclerosis and CAD has been controversial, although data support the concept that various factors, including depression, anxiety, long-term life stress, and hostility or anger, contribute significantly to the pathogenesis of atherosclerosis and the development of major CAD events.Probably most of the early evidence focused on depression as a major risk factor.Moreover, several studieshave demonstrated poor recovery from depression in patients with CAD following major events. In addition to depression, Friedman and Rosenmanhave defined persons who exhibited an emotional syndrome characterized by a continuously harrying sense of time, urgency, aggressiveness, ambitiousness, competitive drive, and easily aroused free-floating hostility as having type A behavior, and some studieshave demonstrated up to a 4-fold increased incidence of clinical CAD in these patients. Recently, hostility has been linked with metabolic syndrome and an increased risk of mortality, especially in younger patients.The role of anxiety with CAD has been most controversial, although several large-scale community-based studieshave demonstrated a link between anxiety and cardiac, especially sudden, death. Most important, the INTERHEART study, which included 29 972 subjects from 52 countries, found that psychosocial factors were a strong independent risk factor for myocardial infarction, composing nearly one third of the population's attributable risk for myocardial infarction.Considerable evidence has demonstrated the substantial benefits of formal phase 2 CRET, including beneficial effects in patients with adverse psychological risk factors.In a recent randomized trial, exercise training decreased depressive symptoms as effectively as antidepressant medication in patients with clinical depression.However, in the field of CRET, most studies have focused on middle-aged or older groups of patients, whereas our study focused on the adverse psychological and overall CAD risk profiles in mostly younger patients following major CAD events. Not only do younger patients experience more obesity and dyslipidemia than do older patients, we also found that the younger patients have a more adverse psychological risk profile, especially hostility and anxiety, that may contribute to the relatively poor prognosis that has been noted in younger patients with CAD.The mechanism by which psychological and behavioral risk factors may cause premature CAD is unclear, but is likely multifactorial, including worsening atherosclerosis risk factors, as suggested by our data, and may directly contribute to atherosclerosis,enhanced platelet reactivity,inflammation,increased catecholamines,and coronary vasoreactivity and vasoconstriction,all of which may increase the risk of CAD events. Anxiety may increase sympathetic activity, reduce vagal tone, and increase the risk of malignant ventricular arrhythmias, all of which may increase the risk of sudden cardiac death.The improvements of psychological risk factors noted in our patients following formal CRET are also probably multifactorial. Cardiac rehabilitation is centered around progressive exercise training, which is known to exert salutary effects on certain emotions and autonomic tone.We have demonstrated that CRET not only improves variables of blood rheology but also has significant benefits for the autonomic nervous system that may be related to the benefits obtained in psychological and behavioral factors.Recent data also emphasize the beneficial effects of exercise on cognitive function and brain plasticity.The education of the patient and the patient's significant other may also be important by increasing understanding of the underlying disease process and its manifestations, thus empowering patients to modify their own recovery. This process of patients becoming more involved in their own health care is called “information involvement,”which may enhance the coping and social and emotional recovery process. In addition, socialization and bonding with other patients who are at various stages of recovery and CRET probably contribute to the favorable effects seen on their adverse psychological risk factors.Previously, a meta-analysis by Linden et alof 23 randomized controlled trials that evaluated the additional impact of psychosocial treatment of rehabilitation demonstrated that this therapy improves psychological distress and biological risk factors (heart rate, systolic pressure, and lipid levels) and reduces major morbidity and mortality. We believe that the benefits obtained in our program are noteworthy, especially because this was accomplished through group sessions for the entire CRET population and individual counseling directed at high-risk behaviors was not included.Several potential study limitations are worth emphasizing. First, we did not include data on a formal control population. However, in several other studiesfrom our CRET programs, including a total of 249 control patients (mostly younger) who did not attend CRET, we identified no improvements over time in the overall CAD risk profile, including behavioral scores and the prevalence of depression, anxiety, and hostility symptoms, which is consistent with other studiesdemonstrating poor spontaneous recovery from depression in patients following major CAD events. Therefore, all of this evidence suggests that the improvements noted following CRET are likely secondary to the intervention introduced and not because of chance or regression to the mean. In addition, our patients received dietary recommendations, including increasing consumption of ω-3 fatty acids as part of a Mediterranean-type diet, which may have an affect on psychological factors.However, patients with and without high psychological risk factors received similar dietary advice, and we did not assess dietary compliance or blood levels of ω-3 fatty acids. Finally, although the scale that we used for the assessment of behavioral characteristics has been validated,its prognostic impact has not been as validated as some other scales commonly used. Nevertheless, our prevalence rates of adverse psychological factors, particularly depression, are quite similar to rates published by others using other validated scales.We believe that our data support the markedly abnormal overall psychological and CAD risk profiles in younger patients with CAD and the substantial benefits that occur following formal CRET programs. Although many young patients with CAD have obstacles to CRET programs, including needing to return to the workforce and family obligations, these data support the need to emphasize formal CRET for their long-term secondary CAD prevention, including routine referral and strongly encouraging young patients to attend and complete these programs.Correspondence:Carl J. Lavie, MD, Department of Cardiovascular Diseases, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121 (clavie@ochsner.org).Accepted for Publication:May 31, 2006.Author Contributions:Drs Lavie and Milani had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.Financial Disclosure:None reported.Previous Presentation:This study was presented in part as a podium presentation to the Annual Scientific Assembly of the American Heart Association; November 8, 2004; New Orleans, La.REFERENCESARozanskiJABlumenthalKWDavidsonPGSaabLKubzanskyThe epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology.J Am Coll Cardiol200545637651TGAllisonDEWilliamsTDMillerMedical and economic costs of psychological distress in patients with coronary artery disease.Mayo Clin Proc1995707347427630210RVMilaniCJLavieBehavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events.Am J Med19961005175238644763NFrasure-SmithFLesperanceMTalajicDepression following myocardial infarction: impact on 6-month survival.JAMA199327018191825[published correction appears in JAMA.1994;271:1082]8411525RVMilaniCJLavieMMCassidyEffects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events.Am Heart J19961327267328831359RVMilaniCJLaviePrevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease.Am J Cardiol199881123312369604957RHRosenmanRJBrandDJenkinsMFriedmanRStrausMWurmCoronary heart disease in Western Collaborative Group Study: final follow-up experience of 8½ years.JAMA19752338728771173896CJLavieRVMilaniPrevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training.Mayo Clin Proc20058033534215757014CDJenkinsMedical progress: recent evidence supporting psychologic and social risk factors for coronary disease (first of two parts).N Engl J Med1976294987994768766SGHaynesMFeinleibWBKannelThe relationship of psychosocial factors to coronary heart disease in the Framingham Study, III: eight-year incidence of coronary heart disease.Am J Epidemiol198011137587352459MFriedmanCEThoresenJJGillAlteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project.Am Heart J1986112653665JCBarefootWGDahlstromRBWilliamsJrHostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians.Psychosom Med19834559636844529CJLavieRVMilaniEffects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility.Mayo Clin Proc19997495996610918860CJLavieRVMilaniPrevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training.Am J Cardiol20049333633914759385CVLavieRVMilaniImpact of aging on hostility in coronary patients and effects of cardiac rehabilitation and exercise training in elderly persons.Am J Geriatr Cardiol200413125130SYusufSHawkenSOunpuuINTERHEART Study InvestigatorsEffect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.Lancet2004364937952ARosengrenSHawkenSOunpuuINTERHEART InvestigatorsAssociation of psychosocial risk factors with risk of acute myocardial infarction in 11,119 cases and 13,648 controls from 52 countries (the INTERHEART study): case-control study.Lancet200436495396215364186TRutledgeSEReisMOlsonPsychosocial variables are associated with atherosclerosis risk factors among women with chest pain: the WISE study.Psychosom Med20016328228811292277LLYanKLiuKAMatthewsMLDaviglusTFFergusonCIKiefePsychosocial factors and risk of hypertension: the Coronary Artery Risk Development in Young Adults (CARDIA) study.JAMA20032902138214814570949ECSuarezPlasma interleukin-6 is associated with psychological coronary risk factors: moderation by use of multivitamin supplements.Brain Behav Immun20031729630312831832CIribarrenSSidneyDEBildAssociation of hostility with coronary artery calcification in young adults: the CARDIA study.JAMA20002832546255110815118SSKnoxAAdelmanRCEllisonHostility, social support, and carotid artery atherosclerosis in the National Heart, Lung, and Blood Institute Family Heart Study.Am J Cardiol2000861086108911074204MCWhitemanIJDearyFGFowkesPersonality and social predictors of atherosclerotic progression: Edinburgh Artery Study.Psychosom Med20006270371411020101JHColeJIMillerIIILSSperlingWSWeintraubLong-term follow-up of coronary artery disease presenting in young adults.J Am Coll Cardiol20034152152812598059AAAwad-ElkarimJPBaggerCJAlbersJSSkinnerPCAdamsRJHallA prospective study of long term prognosis in young myocardial infarction survivors: the prognostic value of angiography and exercise testing.Heart20038984384712860853JFTodaroCAndreaRNiauraASpioIIIKDWardARoytbergCombined effect of the metabolic syndrome and hostility on the incidence of myocardial infarction (the Normative Aging Study).Am J Cardiol20059622122616018847SHBoyleRBWilliamsDBMarkBHBrummetICSieglerJCBarefootHostility, age, and mortality in a sample of cardiac patients.Am J Cardiol200596646615979435PAAdesCardiac rehabilitation and secondary prevention of coronary heart disease.N Engl J Med200134589290211565523NKWengerESFroehlicherLKSmithCardiac Rehabilitation: Clinical Practice Guidelines.Rockville, Md: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute; 1995. AHCPR publication 96-0672BJWittSJJacobsenSAWestonCardiac rehabilitation after myocardial infarction in the community.J Am Coll Cardiol200444988996RKellnerA symptom questionnaire.J Clin Psychiatry1987482682743597327RKellnerBJSheffieldA self-rating scale of distress.Psychol Med19733881004692494ALStewartSGreenfieldRDHaysFunctional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study (published correction appears in JAMA. 1989;262:2542).JAMA1989262907913MJSternLPascaleAAckermanLife adjustment post-myocardial infarction: determining predictive variables.Arch Intern Med197713716801685931475KHLadwigGRollGBreithardtTBuddeMBorggrefePost-infarction depression and incomplete recovery 6 months after acute myocardial infarction.Lancet199434320237905043MFriedmanRHRosenmanAssociation of specific overt behavior pattern with blood and cardiovascular findings: blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease.JAMA195916912861296IKawachiDSparrowPSVokonasSTWeissSymptoms of anxiety and risk of coronary heart disease: the Normative Aging Study.Circulation199490222522297955177JABlumenthalMABabyakKAMooreEffects of exercise training on older patients with major depression.Arch Intern Med19991592349235610547175MBabyakJABlumenthalSHermanExercise treatment for major depression: maintenance of therapeutic benefit at 10 months.Psychosom Med20006263363811020092JHMarkovitzHostility is associated with increased platelet activation in coronary heart disease.Psychosom Med1998605865919773762SFukudoJDLaneNBAndersonAccentuated vagal antagonism of β-adrenergic effects on ventricular repolarization: evidence of weaker antagonism in hostile type A men.Circulation19928520452053PPChangDEFordLAMeoniNYWangMJKlagAnger in young men and subsequent premature cardiovascular disease: the precursors study.Arch Intern Med200216290190611966341MDBoltwoodCBTaylorMBBurkeJGroginJGiacominiAnger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments.Am J Cardiol199372136113658256727JABlumenthalMFredriksonCMKuhnRLUlmerMWalsh-RiddleMAppelbaumAerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia.Am J Cardiol1990659398JABlumenthalRSWilliamsTLNeedelsAGWallacePsychological changes accompany aerobic exercise in healthy middle-aged adults.Psychosom Med198244529536TSChurchCJLavieRVMilaniGSKirbyImprovements in blood rheology after cardiac rehabilitation and exercise training in patients with coronary heart disease.Am Heart J200214334935511835042TKalapuraCJLavieWJaffraniVChilakamarriRVMilaniEffects of cardiac rehabilitation and exercise training on indexes of dispersion of ventricular repolarization in patients after acute myocardial infarction.Am J Cardiol20039229229412888135EMcAuleyAFKramerSJColcombeCardiovascular fitness and neurocognitive function in older adults: a brief overview.Brain Behav Immun20041821422015116743DSKrantzABaumMWidemanAssessment of preferences for self-treatment and information in health care.J Pers Soc Psychol1980399779907441487JAKulikHIMahlerSocial support and recovery from surgery.Health Psychol198982212382786808WLindenCStosselJMauricePsychosocial interventions for patients with coronary artery disease: a meta-analysis.Arch Intern Med19961567457528615707RVMilaniCJLavieMRMehraReduction in C-reactive protein through cardiac rehabilitation and exercise training.J Am Coll Cardiol2004431056106115028366WESeverusABLittmanALStollOmega-3 fatty acids, homocysteine, and the increased risk of cardiovascular mortality in major depressive disorder.Harv Rev Psychiatry2001928029311600487 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Adverse Psychological and Coronary Risk Profiles in Young Patients With Coronary Artery Disease and Benefits of Formal Cardiac Rehabilitation

JAMA Internal Medicine , Volume 166 (17) – Sep 25, 2006

Loading next page...
 
/lp/american-medical-association/adverse-psychological-and-coronary-risk-profiles-in-young-patients-GE7sZBymTd

References (55)

Publisher
American Medical Association
Copyright
Copyright 2006 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/archinte.166.17.1878
pmid
17000945
Publisher site
See Article on Publisher Site

Abstract

BackgroundRecent data indicate that young patients with coronary artery disease (CAD) have a poor long-term prognosis. Although the benefits of formal cardiac rehabilitation and exercise training programs are well established, most of these data come from middle-aged and older patients.MethodsWe assessed baseline behavioral data, quality of life, and risk profiles in 635 consecutive patients with CAD before and after cardiac rehabilitation and exercise training, and specifically assessed data in 104 young patients (mean ± SD age, 48 ± 6 years; range, 22-54 years) compared with 260 elderly patients (mean ± SD age, 75 ± 3 years; range, 70-85 years).ResultsCompared with older patients, young patients had higher body mass indexes (12.2%, P<.001), total cholesterol–high-density lipoprotein ratio (14.6%, P<.01), and triglycerides level (27.2%, P<.01), and a lower high-density lipoprotein cholesterol level (−8.8%, P=.045). Young patients also had higher scores for anxiety and hostility (51.5% and 94.4%, respectively; P<.001 for both), a considerably higher prevalence of anxiety (27.9% vs 13.5%; P<.01) and hostility (12.5% vs 4.6%; P<.01) symptoms, and slightly more depression symptoms (23.1% vs 18.8%) compared with elderly patients. Following cardiac rehabilitation and exercise training, young patients had improvements in body mass index (−1.7%, P<.01), percentage body fat (−4.4%, P<.001), high-density lipoprotein cholesterol level (10.2%, P<.001), high-sensitivity C-reactive protein level (−33.3%, P<.01), peak oxygen consumption (11.3%, P<.001), resting heart rate (−4.5%, P=.01), and resting systolic pressure (−2.3%, P=.049), and marked improvements in scores for depression (−58.5%), anxiety (−46.0%), hostility (−45.7%), somatization (−33.8%), and quality of life (15.8%) (P<.001 for all). Young patients also had greater than 50% to greater than 80% reductions in the prevalence of anxiety (P<.001), hostility (P<.01), and depression (P<.001).ConclusionThese data demonstrate the adverse psychological and CAD risk profiles that are present in young patients with CAD following major CAD events, and are consistent with substantial benefit of formal cardiac rehabilitation and exercise training programs in younger adults.Substantial evidence indicates that psychological distress is a significant coronary artery disease (CAD) risk factor and adversely affects recovery after major CAD events.Although most of this evidence has focused on the high prevalence of depression in patients with CAD and on depression as a CAD risk factor,evidence also indicates that anxiety and hostility are associated with an increase in CAD events.A psychosocial index comprising many of these behaviors has recently been shown to be an independent risk factor for the development of myocardial infarction.Moreover, these psychological risk factors have been associated with dyslipidemia, hypertension, obesity, inflammatory biomarkers, coronary calcium and atherosclerosis, and peripheral atherosclerosis.Although elderly persons compose the largest portion of patients with CAD, recent studiessuggest that younger patients represent a growing segment of the population with CAD and carry a poor long-term prognosis. Researchershave demonstrated the marked benefits of cardiac rehabilitation and exercise training (CRET) programs in secondary CAD prevention, including benefits on standard CAD risk factors and psychological factors; however, most of these studies have been performed in middle-aged and older subjects.The present study determines the baseline psychological and overall CAD risk profiles in many younger patients with CAD and compares them with those of older patients, following a CAD event. We also sought to document the effects of formal phase 2 CRET programs in this young cohort with CAD.METHODSSTUDY POPULATIONWe studied 635 consecutive patients with CAD who were referred to, attended, and completed phase 2 CRET programs at Ochsner Clinic Foundation in New Orleans, following major CAD events (myocardial infarction, unstable angina, or major coronary revascularization), and we specifically assessed detailed data in 104 young patients with CAD (aged <55 years; mean ± SD age, 48 ± 6 years; age range, 22-54 years; 73.1% male) compared with 260 elderly patients (aged ≥70 years; mean ± SD age, 75 ± 3 years; age range, 70-85 years; 75.4% male). We also report baseline data in 52 young patients (aged <55 years; mean ± SD age, 48 ± 5 years; age range, 23-54 years; 76.9% male) and 68 older patients (aged ≥70 years; mean ± SD age, 76 ± 4 years; age range, 70-88 years; 67.2% male) who either enrolled and did not attend formal CRET or dropped out during the program. All patients completed validated questionnaires before and after the CRET program. This study was approved by the institutional review board of Ochsner Clinic Foundation.BEHAVIORAL TESTINGThe Kellner Symptom Questionnaire has been validated to assess behavioral characteristics, including symptoms of depression, anxiety, hostility, and somatization, with a lower score indicating a more favorable behavioral trait (manual of the symptom questionnaire available on request; R. P. Kellner, MD, PhD, written and oral communication, 1986).The Medical Outcomes Study 36-Item Short-Form Health Survey was used to assess the total quality-of-life score using a standardized coding algorithm, with a higher score indicating a more favorable quality of life.Based on prior studies of mean scores in healthy subjects (R. P. Kellner, MD, PhD, unpublished data, January 1987, normal scores (scaled score between 1 and 2 SDs above the mean) for anxiety and hostility are 7 or less; and for depression, less than 7. Therefore, we chose 8 or higher as a cutoff to indicate anxiety and hostility symptoms and 7 or higher for depression symptoms. In addition, we assessed the prevalence of these behavioral symptoms in the younger vs the older patients.PROTOCOLThe protocol, data collection, and statistical analyses were performed as described previously.The CRET program generally lasted 12 weeks and consisted of 36 educational and exercise sessions, with exercise sessions consisting of 10 minutes of warm-up, calisthenics, and stretching, followed by 30 to 45 minutes of continuous aerobic and dynamic exercise and light isometrics, and approximately 5 to 10 minutes of cooldown. Exercise intensity was prescribed close to the anaerobic or ventilatory threshold obtained by baseline cardiopulmonary stress testing and 10 to 15 beats/min below the level of any exercise-induced or silent myocardial ischemia. In addition, we encouraged patients to perform 1 to 3 exercise sessions per week at home and periodically adjusted exercise prescription to encourage a gradual improvement in overall exercise performance. Besides the exercise portion of the program, daily lectures and group sessions were directed by a licensed nurse, an exercise physiologist, or a dietitian, emphasizing all aspects of CAD and prevention. Although patients and their significant others were taught about behavioral factors, stress, and sexual function and could ask questions in all of these areas, we did not routinely provide individual attention to these areas, including individual counseling directed at high-risk patients with adverse behavioral characteristics, including anxiety, hostility or anger management, and depression.At baseline (2-6 weeks after the major CAD event) and again 1 week after the CRET, we obtained several measurements, including height, weight, body mass index, percentage body fat (by the sum of the skinfold method), fasting plasma lipids level, and cardiopulmonary exercise data.STATISTICAL ANALYSESContinuous variables were expressed as mean ± SD. Two-sample ttests and analysis of variance were used to assess differences in baseline characteristics and CRET data between young and older patients, and baseline characteristics were also compared between those completing and those not completing the CRET program. Changes between baseline and post-CRET data were compared using a paired ttest and &khgr;2analysis, with P<.05 used to determine statistical significance. All data analyses were performed with computer software (StatView; SAS Institute Inc, Cary, NC) on a computer system (Macintosh II; Apple Computers, Inc, Cupertino, Calif).RESULTSThe baseline characteristics of the study cohort are demonstrated in Table 1. Young CRET patients comprised 16.4% of patients completing the formal program and had a significantly higher body mass index (12.2%), total cholesterol–high-density lipoprotein cholesterol ratio (14.6%), and triglycerides level (27.2%), and lower levels of high-density lipoprotein cholesterol (−8.8%) and resting systolic blood pressure (−7.1%), than elderly patients. As expected, young patients had considerably higher levels of peak oxygen consumption (&Vdot;O2) (45.7%). In addition, young patients had higher scores for depression (24.2%), hostility (94.4%), and anxiety (51.5%) than did elderly patients and a slightly higher prevalence of depression symptoms and a significantly higher prevalence of anxiety and hostility symptoms (P<.01 for both) than did older patients (Figure). Although many of the baseline characteristics of young patients not completing CRET were slightly more adverse than the characteristics of those completing CRET, only the difference in peak &Vdot;O2was statistically significant (P=.038). Likewise, elderly patients not completing CRET had significantly lower peak &Vdot;O2and higher anxiety scores (P=.042 for both) compared with elderly patients completing CRET.Figure.Prevalence of adverse behavioral characteristics in young (mean ± SD age, 48 ± 6 years) and elderly (mean ± SD age, 75 ± 3 years) patients with coronary artery disease at baseline. The asterisk indicates P<.01.Table 1. Baseline Characteristics of Young and Older Patients With Coronary Artery Disease, Completing and Not Completing Formal Cardiac RehabilitationCharacteristicYoung Completers(n = 104)Young Noncompleters(n = 52)Elderly Completers(n = 260)Elderly Noncompleters(n = 68)PValue*Total cholesterol level, mg/dL168 ± 42178 ± 36168 ± 34170 ± 35.90Triglycerides level, mg/dL173 ± 132186 ± 122136 ± 63159 ± 114<.01High-density lipoprotein cholesterol level, mg/dL39.4 ± 13.238.4 ± 13.843.2 ± 14.042.6 ± 13.2.045Low-density lipoprotein cholesterol level, mg/dL99 ± 29106 ± 5197 ± 2796 ± 26.71Total cholesterol–high-density lipoprotein cholesterol ratio4.7 ± 1.74.6 ± 1.84.1 ± 1.14.0 ± 1.3<.01Body mass index†30.3 ± 5.930.2 ± 6.127.0 ± 4.527.9 ± 4.9<.001Body fat, %29.3 ± 7.029.1 ± 7.628.3 ± 8.128.5 ± 9.0.30Fasting blood glucose level, mg/dL104 ± 25106 ± 26108 ± 21106 ± 24.25High-sensitivity C-reactive protein level, mg/dL4.2 ± 5.46.4 ± 11.45.6 ± 8.17.5 ± 9.5.12Resting blood pressure, mm Hg Systolic130 ± 16132 ± 18140 ± 20141 ± 21<.001 Diastolic76 ± 1377 ± 1474 ± 1376 ± 14.17Peak oxygen consumption, mL/kg per min20.4 ± 5.317.9 ± 5.3‡14.0 ± 3.312.7 ± 3.3‡<.001Depression score, U4.1 ± 4.85.6 ± 5.93.3 ± 3.74.0 ± 4.1.09Hostility score, U3.5 ± 4.74.4 ± 5.21.8 ± 2.72.1 ± 3.0<.001Anxiety score, U5.0 ± 5.46.1 ± 5.13.3 ± 3.84.6 ± 5.2‡<.001Somatization score, U7.4 ± 4.58.9 ± 5.26.9 ± 3.67.3 ± 4.4.25Total quality-of-life score, U101 ± 2195 ± 2299 ± 1993 ± 16.36 SI conversion factors: To convert high-density lipoprotein, low-density lipoprotein, and total cholesterol to millimoles per liter, multiply by 0.0259; to convert glucose to millimoles per liter, multiply by 0.0555; and to convert triglycerides to millimoles per liter, multiply by 0.0113. *Comparison of young and elderly patients who completed rehabilitation. †Calculated as weight in kilograms divided by the square of height in meters. ‡P<.05 compared with completers.Following the CRET programs (Table 2), the young patients had significant improvements in many variables, including obesity indexes, high-density lipoprotein level, high-sensitivity C-reactive protein level, peak &Vdot;O2, resting heart rate, and resting systolic pressure. In addition, young patients had marked improvements in scores for anxiety, depression, hostility, somatization, and quality of life.Table 2. Risk Factor Changes Noted in 104 Young Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*Risk FactorBefore RehabilitationAfter Rehabilitation% ChangePValueBody mass index†30.3 ± 5.929.8 ± 5.7−1.7<.01Body fat, %29.3 ± 7.028.0 ± 7.8−4.4<.001High-density lipoprotein cholesterol level, mg/dL39.4 ± 13.243.4 ± 12.410.2<.001High-sensitivity C-reactive protein level, mg/dL4.2 ± 5.42.8 ± 3.1−33.3<.01Fasting glucose level, mg/dL104 ± 25101 ± 19−2.9.15Peak oxygen consumption, mL/kg per min20.4 ± 5.322.7 ± 6.111.3<.001Resting heart rate, beats/min66 ± 1163 ± 10−4.5.01Resting systolic blood pressure, mm Hg130 ± 16127 ± 17−2.3.049Anxiety, U5.0 ± 5.42.7 ± 3.7−46.0<.001Depression, U4.1 ± 4.81.7 ± 2.9−58.5<.001Hostility, U3.5 ± 4.71.9 ± 3.3−45.7<.001Somatization, U7.4 ± 4.54.9 ± 3.9−33.8<.001Total quality of life, U101 ± 21117 ± 1815.8<.001 SI conversion factors: See Table 1. *There were no significant changes in the other variables studied in young or older patients, including total cholesterol level, triglycerides level, low-density lipoprotein cholesterol level, and resting diastolic blood pressure. †Calculated as weight in kilograms divided by the square of height in meters.Likewise, elderly patients completing CRET also demonstrated significant improvements in most variables studied (Table 3). Although most of the relative improvements following CRET were statistically similar in the younger and older patients, the young patients had significantly greater improvements in body mass index (−1.7% vs −0.4%; P=.03) and hostility score (−45.7% vs −16.7%; P=.05) and a trend for greater improvement in peak &Vdot;O2(11.3% vs 7.1%; P=.09) compared with the elderly patients. Fasting glucose level decreased minimally following CRET in younger patients and increased significantly in older patients; these relative differences were also statistically significant (P = .03).Table 3. Risk Factor Changes Noted in 260 Older Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*Risk FactorBefore RehabilitationAfter Rehabilitation% ChangePValueBody mass index†27.0 ± 4.526.9 ± 4.1−0.4.65Body fat, %28.3 ± 8.127.1 ± 6.9−4.2<.001High-density lipoprotein cholesterol level, mg/dL43.2 ± 14.045.1 ± 14.24.4<.001High-sensitivity C-reactive protein level, mg/dL5.6 ± 8.13.8 ± 5.0−32.1<.01Fasting glucose level, mg/dL108 ± 21119 ± 4010.2.02Peak oxygen consumption, mL/kg per min14.0 ± 3.315.0 ± 3.67.1<.001Resting heart rate, beats/min65 ± 861 ± 7−6.2<.001Resting systolic blood pressure, mm Hg140 ± 20138 ± 18−1.4.10Anxiety, U3.3 ± 3.82.1 ± 3.0−36.4<.001Depression, U3.3 ± 3.71.9 ± 2.8−42.4<.001Hostility, U1.8 ± 2.71.5 ± 2.4−16.7<.01Somatization, U6.9 ± 3.65.3 ± 4.5−23.2<.001Total quality of life, U99 ± 19112 ± 1713.1<.001 SI conversion factors: See Table 1.*There were no significant changes in the other variables studied in older or younger patients, including total cholesterol level, triglycerides level, low-density lipoprotein cholesterol level, and resting diastolic blood pressure. †Calculated as weight in kilograms divided by the square of height in meters.Following CRET, there was a marked decrease in the prevalence of anxiety symptoms (P<.001), with the prevalence of anxiety being equal after CRET in younger and older patients (Table 4). Likewise, the young patients had a greater than 50% decrease in the prevalence of hostility symptoms and a greater than 80% decrease in depression symptoms following CRET.Table 4. Effects of Cardiac Rehabilitation and Exercise Training Programs on Symptoms of Anxiety, Hostility,and Depression in Young and Older Patients With Coronary Artery DiseaseSymptomYoung Patients (n = 104)Older Patients (n = 260)Before Rehabilitation, %After Rehabilitation, %PValueBefore Rehabilitation, %After Rehabilitation, %PValueAnxiety27.98.7<.00113.59.2<.01Hostility12.55.8<.014.62.3<.05Depression23.13.8<.00118.86.2<.001COMMENTThere are 3 important findings from this investigation. First, young patients compose a significant segment of the population with CAD completing formal CRET programs. Second, young patients with CAD are characterized by a higher degree of psychological distress, obesity, and dyslipidemia. Third, these adverse characteristics substantially improved following formal phase 2 CRET programs.The importance of behavioral and psychological risk factors in the pathogenesis and expression of atherosclerosis and CAD has been controversial, although data support the concept that various factors, including depression, anxiety, long-term life stress, and hostility or anger, contribute significantly to the pathogenesis of atherosclerosis and the development of major CAD events.Probably most of the early evidence focused on depression as a major risk factor.Moreover, several studieshave demonstrated poor recovery from depression in patients with CAD following major events. In addition to depression, Friedman and Rosenmanhave defined persons who exhibited an emotional syndrome characterized by a continuously harrying sense of time, urgency, aggressiveness, ambitiousness, competitive drive, and easily aroused free-floating hostility as having type A behavior, and some studieshave demonstrated up to a 4-fold increased incidence of clinical CAD in these patients. Recently, hostility has been linked with metabolic syndrome and an increased risk of mortality, especially in younger patients.The role of anxiety with CAD has been most controversial, although several large-scale community-based studieshave demonstrated a link between anxiety and cardiac, especially sudden, death. Most important, the INTERHEART study, which included 29 972 subjects from 52 countries, found that psychosocial factors were a strong independent risk factor for myocardial infarction, composing nearly one third of the population's attributable risk for myocardial infarction.Considerable evidence has demonstrated the substantial benefits of formal phase 2 CRET, including beneficial effects in patients with adverse psychological risk factors.In a recent randomized trial, exercise training decreased depressive symptoms as effectively as antidepressant medication in patients with clinical depression.However, in the field of CRET, most studies have focused on middle-aged or older groups of patients, whereas our study focused on the adverse psychological and overall CAD risk profiles in mostly younger patients following major CAD events. Not only do younger patients experience more obesity and dyslipidemia than do older patients, we also found that the younger patients have a more adverse psychological risk profile, especially hostility and anxiety, that may contribute to the relatively poor prognosis that has been noted in younger patients with CAD.The mechanism by which psychological and behavioral risk factors may cause premature CAD is unclear, but is likely multifactorial, including worsening atherosclerosis risk factors, as suggested by our data, and may directly contribute to atherosclerosis,enhanced platelet reactivity,inflammation,increased catecholamines,and coronary vasoreactivity and vasoconstriction,all of which may increase the risk of CAD events. Anxiety may increase sympathetic activity, reduce vagal tone, and increase the risk of malignant ventricular arrhythmias, all of which may increase the risk of sudden cardiac death.The improvements of psychological risk factors noted in our patients following formal CRET are also probably multifactorial. Cardiac rehabilitation is centered around progressive exercise training, which is known to exert salutary effects on certain emotions and autonomic tone.We have demonstrated that CRET not only improves variables of blood rheology but also has significant benefits for the autonomic nervous system that may be related to the benefits obtained in psychological and behavioral factors.Recent data also emphasize the beneficial effects of exercise on cognitive function and brain plasticity.The education of the patient and the patient's significant other may also be important by increasing understanding of the underlying disease process and its manifestations, thus empowering patients to modify their own recovery. This process of patients becoming more involved in their own health care is called “information involvement,”which may enhance the coping and social and emotional recovery process. In addition, socialization and bonding with other patients who are at various stages of recovery and CRET probably contribute to the favorable effects seen on their adverse psychological risk factors.Previously, a meta-analysis by Linden et alof 23 randomized controlled trials that evaluated the additional impact of psychosocial treatment of rehabilitation demonstrated that this therapy improves psychological distress and biological risk factors (heart rate, systolic pressure, and lipid levels) and reduces major morbidity and mortality. We believe that the benefits obtained in our program are noteworthy, especially because this was accomplished through group sessions for the entire CRET population and individual counseling directed at high-risk behaviors was not included.Several potential study limitations are worth emphasizing. First, we did not include data on a formal control population. However, in several other studiesfrom our CRET programs, including a total of 249 control patients (mostly younger) who did not attend CRET, we identified no improvements over time in the overall CAD risk profile, including behavioral scores and the prevalence of depression, anxiety, and hostility symptoms, which is consistent with other studiesdemonstrating poor spontaneous recovery from depression in patients following major CAD events. Therefore, all of this evidence suggests that the improvements noted following CRET are likely secondary to the intervention introduced and not because of chance or regression to the mean. In addition, our patients received dietary recommendations, including increasing consumption of ω-3 fatty acids as part of a Mediterranean-type diet, which may have an affect on psychological factors.However, patients with and without high psychological risk factors received similar dietary advice, and we did not assess dietary compliance or blood levels of ω-3 fatty acids. Finally, although the scale that we used for the assessment of behavioral characteristics has been validated,its prognostic impact has not been as validated as some other scales commonly used. Nevertheless, our prevalence rates of adverse psychological factors, particularly depression, are quite similar to rates published by others using other validated scales.We believe that our data support the markedly abnormal overall psychological and CAD risk profiles in younger patients with CAD and the substantial benefits that occur following formal CRET programs. Although many young patients with CAD have obstacles to CRET programs, including needing to return to the workforce and family obligations, these data support the need to emphasize formal CRET for their long-term secondary CAD prevention, including routine referral and strongly encouraging young patients to attend and complete these programs.Correspondence:Carl J. Lavie, MD, Department of Cardiovascular Diseases, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121 (clavie@ochsner.org).Accepted for Publication:May 31, 2006.Author Contributions:Drs Lavie and Milani had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.Financial Disclosure:None reported.Previous Presentation:This study was presented in part as a podium presentation to the Annual Scientific Assembly of the American Heart Association; November 8, 2004; New Orleans, La.REFERENCESARozanskiJABlumenthalKWDavidsonPGSaabLKubzanskyThe epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology.J Am Coll Cardiol200545637651TGAllisonDEWilliamsTDMillerMedical and economic costs of psychological distress in patients with coronary artery disease.Mayo Clin Proc1995707347427630210RVMilaniCJLavieBehavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events.Am J Med19961005175238644763NFrasure-SmithFLesperanceMTalajicDepression following myocardial infarction: impact on 6-month survival.JAMA199327018191825[published correction appears in JAMA.1994;271:1082]8411525RVMilaniCJLavieMMCassidyEffects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events.Am Heart J19961327267328831359RVMilaniCJLaviePrevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease.Am J Cardiol199881123312369604957RHRosenmanRJBrandDJenkinsMFriedmanRStrausMWurmCoronary heart disease in Western Collaborative Group Study: final follow-up experience of 8½ years.JAMA19752338728771173896CJLavieRVMilaniPrevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training.Mayo Clin Proc20058033534215757014CDJenkinsMedical progress: recent evidence supporting psychologic and social risk factors for coronary disease (first of two parts).N Engl J Med1976294987994768766SGHaynesMFeinleibWBKannelThe relationship of psychosocial factors to coronary heart disease in the Framingham Study, III: eight-year incidence of coronary heart disease.Am J Epidemiol198011137587352459MFriedmanCEThoresenJJGillAlteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project.Am Heart J1986112653665JCBarefootWGDahlstromRBWilliamsJrHostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians.Psychosom Med19834559636844529CJLavieRVMilaniEffects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility.Mayo Clin Proc19997495996610918860CJLavieRVMilaniPrevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training.Am J Cardiol20049333633914759385CVLavieRVMilaniImpact of aging on hostility in coronary patients and effects of cardiac rehabilitation and exercise training in elderly persons.Am J Geriatr Cardiol200413125130SYusufSHawkenSOunpuuINTERHEART Study InvestigatorsEffect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study.Lancet2004364937952ARosengrenSHawkenSOunpuuINTERHEART InvestigatorsAssociation of psychosocial risk factors with risk of acute myocardial infarction in 11,119 cases and 13,648 controls from 52 countries (the INTERHEART study): case-control study.Lancet200436495396215364186TRutledgeSEReisMOlsonPsychosocial variables are associated with atherosclerosis risk factors among women with chest pain: the WISE study.Psychosom Med20016328228811292277LLYanKLiuKAMatthewsMLDaviglusTFFergusonCIKiefePsychosocial factors and risk of hypertension: the Coronary Artery Risk Development in Young Adults (CARDIA) study.JAMA20032902138214814570949ECSuarezPlasma interleukin-6 is associated with psychological coronary risk factors: moderation by use of multivitamin supplements.Brain Behav Immun20031729630312831832CIribarrenSSidneyDEBildAssociation of hostility with coronary artery calcification in young adults: the CARDIA study.JAMA20002832546255110815118SSKnoxAAdelmanRCEllisonHostility, social support, and carotid artery atherosclerosis in the National Heart, Lung, and Blood Institute Family Heart Study.Am J Cardiol2000861086108911074204MCWhitemanIJDearyFGFowkesPersonality and social predictors of atherosclerotic progression: Edinburgh Artery Study.Psychosom Med20006270371411020101JHColeJIMillerIIILSSperlingWSWeintraubLong-term follow-up of coronary artery disease presenting in young adults.J Am Coll Cardiol20034152152812598059AAAwad-ElkarimJPBaggerCJAlbersJSSkinnerPCAdamsRJHallA prospective study of long term prognosis in young myocardial infarction survivors: the prognostic value of angiography and exercise testing.Heart20038984384712860853JFTodaroCAndreaRNiauraASpioIIIKDWardARoytbergCombined effect of the metabolic syndrome and hostility on the incidence of myocardial infarction (the Normative Aging Study).Am J Cardiol20059622122616018847SHBoyleRBWilliamsDBMarkBHBrummetICSieglerJCBarefootHostility, age, and mortality in a sample of cardiac patients.Am J Cardiol200596646615979435PAAdesCardiac rehabilitation and secondary prevention of coronary heart disease.N Engl J Med200134589290211565523NKWengerESFroehlicherLKSmithCardiac Rehabilitation: Clinical Practice Guidelines.Rockville, Md: Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute; 1995. AHCPR publication 96-0672BJWittSJJacobsenSAWestonCardiac rehabilitation after myocardial infarction in the community.J Am Coll Cardiol200444988996RKellnerA symptom questionnaire.J Clin Psychiatry1987482682743597327RKellnerBJSheffieldA self-rating scale of distress.Psychol Med19733881004692494ALStewartSGreenfieldRDHaysFunctional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study (published correction appears in JAMA. 1989;262:2542).JAMA1989262907913MJSternLPascaleAAckermanLife adjustment post-myocardial infarction: determining predictive variables.Arch Intern Med197713716801685931475KHLadwigGRollGBreithardtTBuddeMBorggrefePost-infarction depression and incomplete recovery 6 months after acute myocardial infarction.Lancet199434320237905043MFriedmanRHRosenmanAssociation of specific overt behavior pattern with blood and cardiovascular findings: blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease.JAMA195916912861296IKawachiDSparrowPSVokonasSTWeissSymptoms of anxiety and risk of coronary heart disease: the Normative Aging Study.Circulation199490222522297955177JABlumenthalMABabyakKAMooreEffects of exercise training on older patients with major depression.Arch Intern Med19991592349235610547175MBabyakJABlumenthalSHermanExercise treatment for major depression: maintenance of therapeutic benefit at 10 months.Psychosom Med20006263363811020092JHMarkovitzHostility is associated with increased platelet activation in coronary heart disease.Psychosom Med1998605865919773762SFukudoJDLaneNBAndersonAccentuated vagal antagonism of β-adrenergic effects on ventricular repolarization: evidence of weaker antagonism in hostile type A men.Circulation19928520452053PPChangDEFordLAMeoniNYWangMJKlagAnger in young men and subsequent premature cardiovascular disease: the precursors study.Arch Intern Med200216290190611966341MDBoltwoodCBTaylorMBBurkeJGroginJGiacominiAnger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments.Am J Cardiol199372136113658256727JABlumenthalMFredriksonCMKuhnRLUlmerMWalsh-RiddleMAppelbaumAerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia.Am J Cardiol1990659398JABlumenthalRSWilliamsTLNeedelsAGWallacePsychological changes accompany aerobic exercise in healthy middle-aged adults.Psychosom Med198244529536TSChurchCJLavieRVMilaniGSKirbyImprovements in blood rheology after cardiac rehabilitation and exercise training in patients with coronary heart disease.Am Heart J200214334935511835042TKalapuraCJLavieWJaffraniVChilakamarriRVMilaniEffects of cardiac rehabilitation and exercise training on indexes of dispersion of ventricular repolarization in patients after acute myocardial infarction.Am J Cardiol20039229229412888135EMcAuleyAFKramerSJColcombeCardiovascular fitness and neurocognitive function in older adults: a brief overview.Brain Behav Immun20041821422015116743DSKrantzABaumMWidemanAssessment of preferences for self-treatment and information in health care.J Pers Soc Psychol1980399779907441487JAKulikHIMahlerSocial support and recovery from surgery.Health Psychol198982212382786808WLindenCStosselJMauricePsychosocial interventions for patients with coronary artery disease: a meta-analysis.Arch Intern Med19961567457528615707RVMilaniCJLavieMRMehraReduction in C-reactive protein through cardiac rehabilitation and exercise training.J Am Coll Cardiol2004431056106115028366WESeverusABLittmanALStollOmega-3 fatty acids, homocysteine, and the increased risk of cardiovascular mortality in major depressive disorder.Harv Rev Psychiatry2001928029311600487

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Sep 25, 2006

There are no references for this article.