Clinical research study
Impact of Cardiac Rehabilitation on Depression and Its Associated Mortality

Presented in part to the Annual Scientific Sessions of the American Heart Association, Chicago, Illinois, November 2006.
https://doi.org/10.1016/j.amjmed.2007.03.026Get rights and content

Abstract

Purpose

Depression following major cardiac events is associated with higher mortality, but little is known about whether this can be reduced through treatment including cardiac rehabilitation and exercise training. We evaluated the impact of cardiac rehabilitation on depression and its associated mortality in coronary patients.

Patients and Methods

We evaluated 522 consecutive coronary patients (381 men, 141 women; aged 64 ± 10 years) enrolled in cardiac rehabilitation from January 2000 to July 2005 and a control group of 179 patients not completing rehabilitation. Depressive symptoms were assessed by questionnaire at baseline and following rehabilitation, and mortality was evaluated after a mean follow-up of 1296 ± 551 days.

Results

Prevalence of depressive symptoms decreased 63% following rehabilitation, from 17% to 6% (P <.0001). Depressed patients following rehabilitation had an over 4-fold higher mortality than nondepressed patients (22% vs 5%, P = .0004). Depressed patients who completed rehabilitation had a 73% lower mortality (8% vs 30%; P = .0005) compared with control depressed subjects who did not complete rehabilitation. Reductions in depressive symptoms and its associated mortality were related to improvements in fitness; however, similar reductions were noted in those with either modest or marked increases in exercise capacity.

Conclusion

In patients following major coronary events, cardiac rehabilitation is associated with both reductions in depressive symptoms and the excess mortality associated with it. Moreover, only mild improvements in levels of fitness appear to be needed to produce these benefits on depressive symptoms and its associated mortality.

Section snippets

Patients

We retrospectively evaluated 522 consecutive patients who were referred to, attended, and completed phase II cardiac rehabilitation (treatment group) between January 2000 and July 2005. All patients entered the program 2-6 weeks after a coronary event, including acute MI (30%), coronary bypass surgery (35%), and percutaneous coronary intervention (44% of patients; some patients had more than one clinical event). We further evaluated a control group of 179 patients who entered rehabilitation but

Baseline Characteristics

The mean age of the 701 patients in treatment and control groups was 64 ± 11 years, with 72% of the subjects male. The mean ejection fraction was 54 ± 12%, and the mean peak VO2 was 16.2 ± 5.2 mL/kg/min. Depressive symptoms were identified in 139 patients (20%) on entry into rehabilitation (26% controls, 17% treatment; P = .005). Table 1 highlights the baseline differences between treatment and control subjects. Table 2 outlines the baseline differences between treatment and control depressed patients.

Treatment Group Characteristics and Effects of Cardiac Rehabilitation and Exercise Training

Discussion

There are several important implications of this study. First, depressive symptoms are prevalent in the coronary heart disease population, particularly in patients following major coronary events. Second, the presence of depressive symptoms, regardless of age or sex, confers a marked increase in all-cause mortality risk over time. Third, cardiac rehabilitation is associated with a marked reduction in the prevalence of depressive symptoms corresponding to a significant improvement in survival.

References (57)

  • R.V. Milani et al.

    Reduction in C-reactive protein through cardiac rehabilitation and exercise training

    J Am Coll Cardiol

    (2004)
  • J.C. Barefoot et al.

    Depression and long-term mortality risk in patients with coronary artery disease

    Am J Cardiol

    (1996)
  • S. Yusuf et al.

    Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study

    Lancet

    (2004)
  • A. Rosengren et al.

    Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study

    Lancet

    (2004)
  • J.A. Blumenthal et al.

    Depression as a risk factor for mortality after coronary artery bypass surgery

    Lancet

    (2003)
  • D.E. Bush et al.

    Even minimal symptoms of depression increase mortality risk after acute myocardial infarction

    Am J Cardiol

    (2001)
  • R.M. Carney et al.

    Depression as a risk factor for mortality after acute myocardial infarction

    Am J Cardiol

    (2003)
  • C.J. Lavie et al.

    Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly

    J Am Coll Cardiol

    (1993)
  • B.J. Witt et al.

    Cardiac rehabilitation after myocardial infarction in the community

    J Am Coll Cardiol

    (2004)
  • L. Vanhees et al.

    Prognostic value of training-induced change in peak exercise capacity in patients with myocardial infarcts and patients with coronary bypass surgery

    Am J Cardiol

    (1995)
  • J.A. Blumenthal et al.

    Aerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia

    Am J Cardiol

    (1990)
  • R.V. Milani et al.

    Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events

    Am J Med

    (1996)
  • A. Byrne et al.

    The effect of exercise on depression, anxiety and other mood states: a review

    J Psychosom Res

    (1993)
  • E. McAuley et al.

    Cardiovascular fitness and neurocognitive function in older adults: a brief review

    Brain Behav Immun

    (2004)
  • S.J. Schleifer et al.

    The nature and course of depression following myocardial infarction

    Arch Intern Med

    (1989)
  • A.W. Forrester et al.

    Depression following myocardial infarction

    Int J Psychiatry Med

    (1992)
  • D.E. Bush et al.

    Post-myocardial infarction depression

    Evid Rep Technol Assess (Summ)

    (2005)
  • J.S. Rumsfeld et al.

    Depression and cardiovascular disease: a call for recognition

    Circulation

    (2005)
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