Psychological Risk Factors in Cardiac Rehabilitation

Abstract

Psychological factors influence cardiovascular health and health care,1 including among patients in cardiac rehabilitation (CR).2 Patients who complete CR programs also show improvement in many psychological factors.3 Therefore, four psychological factors, with the most rigorous scientific evidence in relation to CR, are presented in brief (Figure).Figure.: Psychological risk factors in cardiac rehabilitation. Abbreviation: CR, cardiac rehabilitation.ANXIETY About one in three patients in CR experience significant anxiety symptoms.4 Anxiety predicts CR engagement, medication adherence, participation in risk factor management and behavioral treatment, functional ability, and quality of life. Patients with anxiety have a greater risk of another cardiovascular event, of cardiac and all-cause mortality, and are more likely to access emergent care.5 Common anxiety symptoms include: Feeling nervous, tense, or on edge Worrying a lot about different things Difficulty controlling worrying Difficulty relaxing Restlessness Irritability Feeling afraid something awful might happen DEPRESSION One third of patients in CR experience depression, which is associated with early treatment discontinuation.6 After a cardiovascular event, depression is associated with higher mortality.5 However, rehabilitation participation is associated with improvement in depression symptoms. A major depressive episode involves depressed or low mood and loss of interest or pleasure most of the day, nearly every day. Depression may also manifest as irritability. Other symptoms of depression include: Weight loss or gain Increased or decreased appetite Fatigue Feeling worthless or guilty Trouble concentrating or making decisions Feeling slowed down in thought or movement (observable by others) Recurrent thoughts of death or suicide The depression symptom burden is associated with significant impairment or distress in numerous health domains. Over the course of routine care, CR can help reduce depressive symptoms. SOCIAL ISOLATION Social isolation is characterized by having few social relationships or infrequent social interactions. Loneliness is the subjective distressing feeling of being alone or separated. Nearly one quarter of older adults are socially isolated and 43% report feeling lonely.7 Social isolation and loneliness are associated with increased morbidity due to cardiovascular disease and stroke. Socially isolated individuals also have a greater likelihood of mortality following myocardial infarction. However, strong social support is consistently associated with better CR attendance, fewer hospitalizations, and longer survival.8 Programs devoted to CR should evaluate social support aligned with Medicare guidelines. Social support may be bolstered through a supportive rehabilitation environment, community resources, and individual and/or small group education and counseling, ideally including support person(s) of patients.2 ANGER/HOSTILITY Anger is an emotional state characterized by antagonism that ranges in intensity from irritation to rage. Hostility is a trait that is characterized by cynical attitudes, distrust, and aggression. Acute and frequent bouts of anger as well as higher levels of hostility have been associated with increased cardiovascular health risk including incident cardiovascular events and diseases, a worse prognosis for patients with cardiovascular diseases, and a higher incidence of cardiovascular disease-related mortality.6,9,10 Signs of anger and hostility include: Blaming, criticizing, or putting down others Being argumentative Easily annoyed or provoked Desire to punish or retaliate In addition to stand-alone psychological interventions, CR participation is shown to reduce anger and hostility among patients.

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