Brief cognitive behavioral therapy (CBT) added to cardiac rehabilitation (CR) is associated with decreased anxiety and depression, improved heart-related quality of life (HeartQoL), and reduced cardiovascular readmissions in patients with cardiac disease and psychological distress, according to a study (ClinicalTrials.gov Identifier: NCT04254315) in the European Heart Journal.
Researchers assessed the effect of brief group CBT with CR to reduce psychological distress in patients with a new coronary artery disease (CAD) event and/or surgically treated valvular heart disease (VHD) and symptoms of anxiety, depression, or both. All participants were referred to CR, had a hospital anxiety and depression scale (HADS) score of 8 or higher for HADS-anxiety (A) and/or HADS-depression (D), and were aged younger than 65 years or were occupationally active if older than 65 years.
The patients were randomly assigned to CR with 5 sessions of group CBT (intervention group) or CR alone (control group). CR programs involved exercise twice weekly for 8 weeks. CBT was a psychoeducational group course led by an experienced cardiac nurse in a 2-hour session per week. A nonrandomized group of patients who met the inclusion criteria but were without signs of psychological distress (HADS-A of less than 8 and HADS-D of less than 8) were included as the background group and received usual CR with re-evaluation after 3 and 6 months.
The primary outcome was the change in psychological distress based on the HADS total score at 3 months in the intervention group compared with the usual care group.
A total of 147 patients were enrolled from February 2017 to March 2021, 74 patients were in the intervention group, 73 were in the control group, and 41 were in the background group. Participants’ overall mean age was 54±8 years, 67% were men, and 92% had CAD as their index event.
The mean total HADS score at 3 months improved by 8.0 (SD, 5.6) points in the intervention group compared with 4.1 (SD, 7.8) in the control group (P for difference <.001). The anxiety and depression subscales also improved significantly more in the intervention group, and the differences were maintained at 6 months.
The 3 groups had significant improvement in HeartQoL, with no significant difference at 3 months between the intervention and control groups in global score or physical/emotional subscores. Significant differences were observed at 6 months in favor of the intervention group for total and emotional score but not for the physical score (P =.05). HeartQoL in the background group was significantly higher (P <.001) at baseline and remained higher at 3 and 6 months compared with the groups with psychological distress.
Of the participants who were distressed, 78% returned to work at 6 months in the intervention group vs 67% in the control group (P =.11).
In the intervention group, 1 patient died from cancer after 12 months. Cardiovascular readmissions occurred in 25% of patients in the intervention group and 49% in the control group. The hazard ratio for hospital admission in the intervention group compared with the control group after adjustment for center was 0.43 (95% CI, 0.24-0.80). In the background group, 5 patients had 1 or more cardiovascular readmissions.
Among several study limitations, the participants had signs of psychological distress at enrollment but were without psychiatric diagnosis or treatment, and only those who were referred to CR were included. In addition, it was not possible to blind patients and CR staff to group allocation, and the intervention group received CBT and CR, which results in a greater number of patient contact hours and may have contributed to the effect.
“…CBT seems an effective treatment for anxiety and depression in patients with CAD and VHD,” wrote the researchers. “The program is simple, feasible, and may be integrated within existing CR programs. Whether a similar effect can be achieved in other cardiac patients with psychological distress and whether the effects are maintained are yet to be discovered.”
Holdgaard A, Eckhardt-Hansen C, Lassen CF, et al. Cognitive-behavioural therapy reduces psychological distress in younger patients with cardiac disease: a randomized trial. Eur Heart J. Published online January 18, 2023. doi: 10.1093/eurheartj/ehac792