This section addresses important psychosocial issues and their implications for cardiac patients.
The section starts with a broad overview of psychosocial research in cardiac populations.
This provides some historical perspective and covers issues such as the influence of the work- place and economics on well-being and cardio- vascular function. Many notable associations have been documented but the causal mecha- nisms, and thus methods of intervention, are much less clear.
The overall goals of cardiac rehabilitation have been described as promoting secondary prevention and improving quality of life. The second contribution in the section describes the concept of health-related quality of life and shows how this patient-focused marker of success in the clinical setting is becoming much more important in medicine in general, including in cardiac populations. Clearly, since much of the prevention and management of cardiac conditions is in the hands of the patient, activities and interventions that have a serious cost to quality of life will not be easily undertaken by patients. One of the challenges facing professionals is to understand the quality of life impact of health recommendations on patients. In parallel, cardiology needs an agreed set of instruments to assess these issues if it is to become as focused as other specialties in arguing for resources for patient care. This challenge is discussed and the most widely used instruments described.
Managing mental health challenges such as stress and depression is the focus of two chapters
in this section. These are important in their own right but also as important barriers to adherence. The epidemiology and impact of depression in cardiac settings is described, as is the challenge of assessing and treating this depression. What is clear is both the damaging nature of depression for cardiac patients and the fact that it is not a short-term response to an acute cardiac event.
The concept of stress and of stress manage- ment procedures suited to a cardiac setting is described. This is coupled with a general chapter on the educational role intrinsic in good care for cardiac patients. It is a reminder of the need to see the busy cardiac setting from the perspective of the patient and family members and to be ever mindful that what is a daily job for professionals is a unique, almost always anxiety-provoking and even possibly a very frightening experience for the patient and family.
Promoting secondary prevention is essenti- ally about promoting adherence to professional guidelines. It is notable how little attention this essential component in the management of patients has been given. The chapter on adherence shows just how big a challenge this is and highlights aspects of patients, professionals and systems that promote or militate against adherence.
Overall, the section aims to demonstrate the important psychosocial issues in cardiac patient care, to show that there is already a wealth of knowledge and informed practice in the area, and to provide a flavor of the research and
Section VI
Psychological and Behavioral Support
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clinical challenges in this area in the coming decades.
Main Messages
Chapter 30: Psychosocial Aspects in Prevention and Rehabilitation
Evidence that psychosocial factors are important in the development and prognosis of cardiovas- cular disease is outlined. Psychosocial problems are common among patients with psychosocial risk factors fitting broadly into two categories;
external factors (such as financial and socioeco- nomic circumstances, life events, and work stress);
and internal factors (such as anxiety, depression, hostility anger, and perception of external cir- cumstances). The most extensive evidence that psychosocial factors are involved in prognosis in coronary heart disease (CHD) derives from work related to depression. In established CHD, depres- sion is associated with a significantly increased risk for recurrent major cardiac events, particu- larly if there is also a lack of social support. The exact pathophysiological nature of the influence of psychosocial factors remains to be determined, as does the temporal sequence of events. Several interventions have been investigated, both to reduce psychosocial risk factors and to improve outcomes in cardiac patients. These include exer- cise training, psychosocial interventions, and pharmacotherapy. There is as yet little evidence that pharmacological treatment for depression can improve cardiac outcomes. Evidence suggests that exercise may modify psychosocial risk factors, including depression, while psychosocial interventions in post-MI patients have found some but not uniformly positive results. Even though there is now substantial evidence of the importance of psychosocial factors in CHD, there is still a lack of systematic knowledge about inter- vention approaches. An ever-increasing literature on psychosocial factors, with significant invest- ment in psychosocial intervention studies includ- ing randomized trials, means that evidence in the coming decade is likely to dramatically increase our understanding of psychosocial contributors to both prevention and rehabilitation in cardiac disease.
Chapter 31: Health-Related Quality of Life in Cardiac Patients
This chapter deals with the concept of health- related quality of life (HRQoL) in the cardiac context. It overviews definitions of HRQoL and the main uses for the concept in research, clinical, and policy settings. The various categories of mea- sures are then described – generic, health-related, disease-specific, individualized, and utility mea- sures. Illustrations for the cardiac setting are pro- vided. Examples of the HRQoL research endeavor are provided by condition (e.g. myocardial in- farction and heart failure) and by procedure or intervention (e.g. cardiac surgery and cardiac rehabilitation). There is increasing evidence of incorporation of HRQoL measures in cardiovas- cular clinical trials. The current challenges in the cardiac research area are described. A major challenge is lack of consensus on instrument choice. This limits comparability across studies and conditions and slows the development of a cumulative evidence base on HRQoL in cardiac conditions. Projects that advise on in- strument selection and use for the future are described.
Chapter 32: Depression Following
Myocardial Infarction: Prevalence, Clinical Consequences, and Patient Management
Depressive symptoms and major depression have been consistently reported as common psycho- logical reactions to myocardial infarction (MI). It has also been argued, on the basis of prospective observational evidence, that depression following MI constitutes an independent, that is, causal, risk for subsequent mortality and morbidity. Two recent meta-analyses have examined this evi- dence. Unadjusted pooled analyses of both meta- analyses indicate that depression following MI is associated with a 2-fold increased risk of death and recurrent cardiac events. However, with adjustment for potential confounders the associa- tions between depression and these outcomes were attenuated. In addition, two recent random- ized trials addressing depression in MI patients (SADHART and ENRICHD) observed a relative reduction in depression with treatment, but found no effects of treatment on mortality, nonfatal rein-
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farction, or indices of disease severity such as left ventricular ejection fraction. On balance, the evi- dence at this stage suggests that claims of causal- ity should be treated with caution. Further randomized controlled trials are needed, as are observational studies that adjust for potential confounders, most importantly for measures of disease severity. Irrespective of the implications of depression following MI for mortality and mor- bidity, the high incidence of depression in this population and the link between depression and impaired quality of life should, however, be sufficient to suggest changes to patient manage- ment practices.
Chapter 33: Educating Cardiac Patients and Relatives
Spouses and family have a very important place in the rehabilitation of patients with coronary heart disease (CHD). Their involvement has the poten- tial of facilitating the process and improving the outcome. The most important source of social support for a cardiac patient is family, particularly his or her spouse. Positive social support is im- portant for the prognosis of CHD patients. This entails emotional (understanding and acceptance of feelings), appraisal (good advice and opportu- nity to discuss how to manage the new life situation), informational (knowledge about CHD, risk factors, and lifestyle), and instrumental (help with practical problems) support. These aspects should be included in comprehensive cardiac rehabilitation and secondary prevention.
In terms of support, it is also the case that
“too much” support from family to the patient can create over-protectiveness and decrease the patient’s self-efficacy and own initiatives in rehabilitation.
A cardiovascular event is of course also a major negative event for family members. In order for spouses and family members to be able to provide adequate social support, they themselves need support. Spouse and family support can be offered in a group format in cardiac rehabilita- tion programs. There is evidence that socially isolated CHD patients are at significantly increased risk of further events. These patients need more active support interventions. In sum, the family can be an important asset in
the care of the cardiac patient but this must be done in a way that addresses the family’s own needs and concerns and enables them to be informed, confident supporters of the patient in their midst.
Chapter 34: Stress Management
Stress management training aims to change envi- ronmental triggers to the stress response and/
or change inappropriate behavioral, physiological, or cognitive responses that occur in response to this event. High levels of muscular tension can be reduced through relaxation techniques; triggers can be identified and modified using problem- solving strategies; cognitive distortions can be identified and changed through cognitive tech- niques such as cognitive restructuring; and
“stressed” behaviors can be changed through con- sideration and rehearsal of alternative behavioral responses.
Many stress management programs teach simple relaxation techniques to minimize high levels of arousal. More complex interventions try to change cognitive (and therefore emotional) reactions to environmental triggers. A few address factors that initiate the stress response. Given the idiosyncratic nature of both the stressors that individuals experience and the complexity of changing their cognitive response, such interven- tions are often led by stress management special- ists, and are best targeted at individuals experiencing significant stress. Relaxation skills are learned through three phases: learning basic relaxation skills; monitoring tension in daily life;
and using relaxation at times of stress. Two strate- gies for changing cognitions are used. Self- instruction training interrupts the flow of stress-provoking thoughts by replacing them with pre-rehearsed stress-reducing or “coping”
thoughts. Cognitive restructuring involves identi- fying and challenging the accuracy of stress- engendering thoughts. Basic interventions, particularly relaxation, can be taught by most healthcare professionals in a group context. The problem-focused or cognitive interventions can be taught by professionals familiar with the issues.
However, where an individual reports high levels of stress, these may best be implemented by more specialist mental health professionals.
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Chapter 35: Adherence to Health Recommendations
Adherence is the single most important modifiable factor that compromises therapeutic outcome across a wide spectrum of diseases.
The most efficacious treatment is made ineffective if the patient fails to adhere to it. Non-adherence produces unnecessary medical and psychosocial consequences of CHD, reduces quality of life, and wastes valuable healthcare resources. Adher- ence to health-related recommendations is thus a major challenge for prevention and rehabilita- tion in cardiovascular disorders. As many as half of all patients advised about long-term management of their condition do not adhere to recommendations. Cardiac rehabilitation (CR) provides a method of promoting patient adherence in secondary prevention for cardio- vascular patients. Adherence can be considered to have illness-related aspects, patient aspects, and health professional/health system aspects.
Side-effects of medications and complex
regimens discourage adherence. However, sociodemographic factors such as age, gender, ethnicity, socioeconomic status, and education have not been consistently related to adherence.
Patient beliefs about treatments and health conditions appear to make a difference while negative psychological states such as depression and anxiety increase non-adherence. Non- adherence has also been associated with poorly developed health services, lack of training in chronic disease management for health, and short consultation times. Interventions to improve adherence have had weak to moderate effects.
However, even modest improvements in adher- ence may result in substantial mortality and economic savings. Adherence has been identified as a core outcome goal for cardiac rehabilitation services. Future research thus needs to identify those patients at highest risk for non-adherence and strategies that facilitate long-term adherence to recommendations since long-term behavior change is intrinsic to much of the potential to benefit.
