Efficacy of psychological interventions on clinical outcomes of coronary artery disease: Systematic review and meta-analysis

Psychological eHealth Interventions for Patients With Cardiovascular Diseases: Systematic Review and Meta-Analysis

BACKGROUND

Psychological distress is recognized as an independent risk factor for cardiovascular diseases (CVDs), contributing to increased morbidity and mortality. While eHealth is increasingly used to deliver psychological interventions, their effectiveness for patients with CVDs remains unclear.

OBJECTIVE

This meta-analysis aimed to evaluate the effects of eHealth psychological interventions for patients with CVDs.

METHODS

Eligible studies were retrieved from 5 databases (Embase, Medline, PubMed, CINAHL, and Cochrane Library), covering the period from database inception to December 2024. Randomized controlled trials (RCTs) investigating the effect of evidence-based psychological eHealth interventions to improve psychosocial well-being and cardiovascular outcomes for people with CVDs were included. The Cochrane Risk of Bias tool (version 2) was used to judge the methodological quality of reviewed studies. RevMan (version 5.3) was used for meta-analysis.

RESULTS

A total of 12 RCTs, comprising 2319 participants from 10 countries, were included in the review. The results demonstrated significant alleviation of depressive symptoms for patients receiving psychological eHealth intervention compared to controls (number of paper included in that particular analysis, n=7; standardized mean difference=-0.30, 95% CI -0.47 to -0.14; I2=57%; P<.001). More specifically, in 6 trials where internet-based cognitive behavioral therapy was delivered, a significant alleviation of depressive symptoms was achieved (standardized mean difference=-0.39, 95% CI -0.56 to -0.21; I2=53%; P<.001). There was no significant change in anxiety or quality of life. Synthesis without meta-analysis regarding stress, adverse events, and cardiovascular events showed inconclusive findings.

CONCLUSIONS

Psychological eHealth interventions, particularly internet-based cognitive behavioral therapy, can significantly reduce depressive symptoms among patients with CVDs. A multidisciplinary approach is crucial for comprehensively improving psychological and cardiovascular outcomes. Future studies should explore integrating persuasive design features into eHealth and involving mental health professionals for intervention delivery.

TRIAL REGISTRATION

PROSPERO CRD42023452276; https://www.crd.york.ac.uk/PROSPERO/view/CRD42023452276.

Cognitive behavioural therapy targeting cardiac anxiety post-myocardial infarction: results from two sequential pilot studies

Aims

Cardiac anxiety, which is cardiac-related fear and avoidance behaviours, is common following myocardial infarction (MI) and has been associated with increased risk for cardiovascular events. However, there are currently no treatments specifically designed to target cardiac anxiety. The aim of the two pilot studies was to evaluate an exposure-based cognitive behavioural therapy protocol (MI-CBT) targeting cardiac anxiety following MI, assessing feasibility, acceptability, and the intervention's potential for reducing cardiac anxiety and improving health-related quality of life (QoL).

Methods and results

A series of two sequential, uncontrolled pilot studies were conducted. In Pilot Study 1 (n = 15), MI-CBT was delivered via face-to-face videoconference, while Pilot Study 2 (n = 23) was delivered online. Patients with a history of MI (≥6 months before assessment, type 1 ST- or non-ST-segment elevation MI, and elevated cardiac anxiety as per clinical interview) were included. The interventions lasted 8 weeks and were therapist-led, with key components including exposure to cardiac-related symptoms and reduction of avoidance behaviours. Participants completed self-rated assessments, including the Cardiac Anxiety Questionnaire (CAQ) and the 12-Item Short Form Health Survey (SF-12), at baseline, post-treatment, and 6-month follow-up. Treatment adherence and satisfaction were high. Cognitive behavioural therapy led to a large reduction in cardiac anxiety, as measured by the CAQ (P < 0.001), and significant improvements in health-related QoL, as measured by the SF-12 (P < 0.001), in both pilot studies.

Conclusion

These studies suggest that exposure-based CBT is a feasible, acceptable, and promising approach to reduce cardiac anxiety and improve QoL following MI. A randomized controlled trial should be conducted to evaluate the efficacy of the intervention.

Effects of psychological interventions on clinical outcomes in patients with cardiovascular diseases: A systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis to evaluate the effects of psychological interventions on the clinical outcomes of patients with cardiovascular diseases (CVDs).

METHODS

We searched PubMed, Web of Science, Embase, the Cochrane Library, and CINAHL from the establishment of each database to August 1, 2023. Randomized controlled trials (RCTs) on psychological interventions in patients with CVDs were included. Statistical analyses were performed using Review Manager 5.3 and Stata 17.0, and pooled measures were presented as the relative risk (RR) and 95 % confidence interval (CI).

RESULTS

A total of 32 studies were included, involving 15,814 patients. Our results showed that psychological interventions could reduce cardiac mortality (RR = 0.81, 95 % CI = 0.68 to 0.96) and the occurrence of myocardial infarction (MI) (RR = 0.79, 95 % CI = 0.69 to 0.89), arrhythmia (RR = 0.61, 95 % CI = 0.42 to 0.89) and angina (RR = 0.92, 95 % CI = 0.87 to 0.97). However, no statistically significant differences were detected in the risk of all-cause mortality, all-cause rehospitalization rates, cardiac rehospitalization rates, revascularization, heart failure (HF), or stroke between the psychological intervention and control groups.

CONCLUSIONS

Psychological interventions can reduce cardiac mortality and the occurrence of MI, arrhythmia, and angina in patients with CVDs. It is crucial to incorporate psychological interventions into the existing treatment and management of patients with CVDs. High-quality RCTs should be conducted to explore the optimal psychological intervention methods and the maximum beneficiaries.

PsicoCare: a pilot randomized controlled trial testing a psychological intervention combining cognitive-behavioral treatment and positive psychology therapy in acute coronary syndrome patients

Background

Although psychological factors play a significant role in the onset and prognosis of acute coronary syndrome (ACS), psychological interventions (PIs) are rarely included in cardiac rehabilitation (CR) programs due to inconclusive evidence regarding specific intervention components and effect sizes. This study aimed to assess the efficacy of a PI based on cognitive-behavioral treatment (CBT) and positive psychology therapy (PPT) in improving psychological and clinical outcomes in patients with ACS.

Methods

This PsicoCare trial was an open-label randomized controlled trial that compared a combined CBT and PPT-based PI (the PsicoCare program) with a standard CR program (control group). We recruited 87 ACS patients, and psychological outcomes, functional capacity, biochemical and anthropometric measures, and clinical outcomes were assessed at baseline, 2 months, and 9 months after the ACS event.

Results

The PsicoCare group showed significant improvements in depression, anger traits, anger-in, and anger control-out compared to the control group. Additionally, the PsicoCare intervention was associated with the improved maintenance of cognitive function, social support, and spiritual coping styles, while the control group showed deterioration in these areas. Patients experiencing severe ACS showed significant improvement in personal strength and meaning as a result of the PsicoCare intervention. However, no significant effects were observed on anxiety, anger-out, emotion regulation skills, dispositional optimism, other personal strengths, or quality of life. Both groups demonstrated similar improvements in functional capacity and clinical outcomes.

Conclusion

The study suggests that CBT and PPT-based PIs may offer additional benefits for ACS patients, particularly regarding their psychological health. Further larger trials are required to confirm these findings.

Clinical trial registration

identifier, NCT05287061.

Lifestyle factors as determinants of atherosclerotic cardiovascular health

A sedentary lifestyle, low levels of physical activity and fitness, poor dietary patterns, and psychosocial stress are strongly associated with increased morbidity and mortality from atherosclerotic cardiovascular disease (ASCVD). Conversely, engaging in regular physical activity, maintaining optimal fitness levels, adhering to a heart-healthy dietary pattern, effectively managing body weight, ensuring adequate sleep, implementing stress-reduction strategies, and addressing psychosocial risk factors are associated with a reduced risk of ASCVD. This comprehensive review synthesizes current evidence from large observational studies and randomized controlled trials on lifestyle factors as determinants of ASCVD health. It also briefly reviews mechanistic insights into how factors such as low shear stress, increased reactive oxygen species production, chronic inflammation, platelets and coagulation activation, endothelial dysfunction, and sympathetic hyperactivity contribute to the initiation and exacerbation of ASCVD risk factors. These include obesity, hyperglycemia, type 2 diabetes, hypertension, and dyslipidemia, subsequently leading to the development and progression of atherosclerosis, ultimately resulting in chronic ASCVD or acute cardiovascular events. To bridge the translational gap between epidemiologic and trial-based evidence and clinical practice, practical recommendations are summarized to facilitate the translation of scientific knowledge into actionable interventions to promote ASCVD health. Acknowledged is the gap between the evidence-based knowledge and adoption within healthcare systems, which remains a crucial objective in advancing cardiovascular health at the population level.

The Role of the Clinical Psychologist in the Care of Adults With Cardiovascular Disease

Cardiovascular disease (CVD) is on the rise globally and, along with mental health conditions, will represent the largest public health burden, especially in a world impacted by climate change. Behavior, psychological mechanisms, and CVD are closely correlated. Evidence-based psychological interventions targeting behavior and psychological mechanisms exist across the CVD spectrum. This statement proposes the development of a subspecialty "cardiovascular psychology" to develop integrated pathways of behavioral care delivered to CVD populations. Scope of practice is discussed as it relates to diagnosing and treating comorbid health disorders, behavioral change interventions, pain management, lifestyle and wellbeing, neuropsychological assessment, and cognitive rehabilitation. An agenda on reforms for financials, training pathways, and diversification of the workforce is presented. Finally, normalizing the integration of behavioral health as part of CVD treatment is a shared responsibility across professional organizations and the community to realize value-based CVD care.

Life satisfaction components and all-cause and cause-specific mortality: A large prospective cohort study

BACKGROUND

Which life satisfaction components could be a target of positive psychological interventions for longevity is largely unknown. We aimed to investigate association of the composite measure of life satisfaction and its individual components with mortality.

METHODS

This cohort study included UK Biobank participants who responded to questions concerning five components of life satisfaction at baseline. We generated a composite score representing overall life satisfaction, ranging from 0 (lowest) to 5 (highest). The outcomes were all-cause and cause-specific mortality. We used multivariable Cox regression to estimate hazard ratios (HR) for the associations of interest.

RESULTS

Among 165,842 eligible participants, 12,261 all-cause deaths were observed over a median of 12.9-year follow-up. Overall life satisfaction was inversely associated with all-cause mortality (adjusted HR 0.94 [95% CI: 0.93-0.95] per 1 score increment). Health satisfaction showed the strongest association with all-cause mortality, with a fully adjusted HR of 0.52 (95% CI: 0.49-0.55) for high/extreme satisfaction and 0.63 (95% CI: 0.59-0.66) for moderate satisfaction, compared with unsatisfaction (P-trend<0.001), independent of other satisfaction components, regardless of physical health and sociodemographics. The association for family, friendship, work and financial satisfaction was attenuated when adjusted for other life satisfaction components. Similar findings were observed for cause-specific mortality.

LIMITATIONS

Observational study with single baseline measurement of life satisfaction precludes the ability to establish causal relationship.

CONCLUSIONS

Higher overall life satisfaction was associated with lower mortality. As the major contributor to lower mortality regardless of physical health and sociodemographics, health satisfaction could be an important target of positive psychological interventions for longevity.

Psychological Health and Ischemic Heart Disease in Women: A Review of Current Evidence and Clinical Considerations across the Healthspan

PURPOSE OF REVIEW

Psychological health encompasses a constellation of negative and positive factors-i.e., psychosocial stress, depression, anxiety, trauma, loneliness and social isolation, anger and hostility, optimism, and a sense of purpose. This narrative review presents current evidence at the intersection of psychological health, risk of ischemic heart disease (IHD), and IHD-related outcomes, with an emphasis on associations in women.

RECENT FINDINGS

For women, relations between psychological health and IHD reflect important sex and gender differences in biological and psychosocial factors. Although efforts devoted to understanding psychological health and IHD risk have varied by psychological factor-scientific evidence is strongest for psychosocial stress and depression, while anxiety, trauma, and positive psychological factors warrant more investigation-less optimal psychological health is consistently associated with an earlier and greater risk of IHD morbidity and mortality in women. Still, many past prospective studies of psychological factors and IHD risk had a limited representation of women, did not include analyses by sex, or failed to account for other influential, sex-specific factors. Thus, there are multiple pathways for further, rigorous investigation into psychological health-IHD associations, mechanisms, and empirically supported psychological interventions to mitigate IHD risk among women. Given the robust evidence linking psychological health with women's risk for IHD, implementing routine, brief, psychological screening is recommended. Significant life events, developmental milestones specific to women, and IHD diagnoses or events could cue further psychological assessment and referral, efforts which will mutually strengthen the evidence for integrated psychological and IHD care and delivery of such care to this vulnerable group.

Feasibility of a brief, in-patient coping and sleep intervention to reduce potentially preventable readmission of cardiac patients to hospital

Background

Psychological distress is prevalent amongst hospital in-patient and may predispose patients to potentially preventable readmissions after discharge. A particularly vulnerable group are patients with cardiac disorders. This study tested the feasibility of a brief cognitive behavioural therapy consisting of an in-hospital coping session and a post-discharge healthy sleep session.

Methods

Standardised questionnaire were used to assess sleep, coping/distress and wellbeing at baseline (pre-intervention) and one-month post-discharge (post-intervention). Treatment fidelity and acceptability were assessed at follow-up. Participants included 72 inpatients admitted with a cardiac disorder or reported to have a cardiac problem whilst in hospital from a single Australian public hospital.

Results

Most (83 %) participants found the intervention helpful/very helpful. At baseline prior to admission, almost half of participants (46 %) reported poor wellbeing, 19 % high levels of distress and poor coping, and 47 % sleeping less than 7 h per night. Following the intervention, 45 % of participants with poor wellbeing at baseline had reliable change in wellbeing at follow-up. Conversely, only 22 % of patients with high levels of coping/distress at baseline demonstrated improved coping/distress at follow-up suggesting smaller gains. On average a large 43 min gain in sleep duration was observed post-treatment in patients with poor sleep at baseline. Fourteen percent of participants were readmitted to hospital within 34-days of discharge.

Conclusions

The coping and sleep intervention was well received with positive outcomes in patients especially those reporting high levels of distress for sleep and to lesser extent coping and wellbeing. Future studies to assess the efficacy of the brief intervention at reducing hospital readmissions are needed.

Cognitive behavioral therapy for depression in patients with heart failure: a systematic review and metanalysis of randomized control trials

Major depression (MD) is prevalent in patients with heart failure (HF) and contributes to increased risk of hospitalization and mortality. The implementation of cognitive behavioral therapy (CBT) has become a key strategy for treating HF patients' depression. We performed a comprehensive literature search for studies that evaluated the efficacy of adjunctive CBT compared to the standard of care (SOC) in HF patients with MD. The primary outcome was the depression scale (post-intervention and by the end of follow-up). The secondary outcomes were the quality of life (QoL), self-care scores, and 6-min walk test distance(6-MW). The standardized mean difference (SMD) and corresponding 95% confidence intervals (CIs) were calculated using the random-effects model. A total of 6 RCTs with 489 patients (244 in the CBT group and 245 in the SOC group) were included. As compared to the SOC, CBT was associated with a statistically significant improvement in the post-interventional depression scale (SMD: -0.45, 95%CI: -0.69, -0.21; P < 0.01) and by the end of follow-up (SMD: -0.68, 95%CI: -0.87, -0.49; P < 0.01). Furthermore, CBT significantly improved the QoL (SMD: -0.45, 95%CI: -0.65, -0.24; P < 0.01). However, there were no differences in the self-care scores (SMD: 0.17, 95%CI: -0.08, 0.42; P = 0.18) or in 6-MW (SMD: 0.45, 95%CI: -0.39, 1.28; P = 0.29) between the two groups. According to our meta-analysis of published clinical studies, CBT may be more effective than standard therapy at enhancing depression scores and quality of life. To assess the long-term clinical effects of CBT in heart failure patients, larger and more powerful RCTs are required.

Sex differences in potential triggers of myocardial infarction

Aims

Internal and external triggers affect seasonal and circadian variations of myocardial infarction (MI). We aimed to assess sex differences in the common triggers of MI.

Methods and results

A nationwide, retrospective, cross-sectional postal survey study was conducted. Individuals who experienced a MI during holidays and weekdays were identified through the SWEDEHEART registry. Twenty-seven potential MI triggers were rated in regards to occurring more or less than usual during the last 24 h before the MI. Three areas were covered: activities, emotions, and food or alcohol consumption. A logistic regression model was used to identify sex differences for each trigger and odds ratios (ORs) were reported. Four hundred and fifty-one patients, of whom 317 were men, responded. The most commonly reported triggers were stress (35.3%), worry (26.2%), depression (21.1%), and insomnia (20.0%). Women reported emotional triggers including sadness [OR 3.52, 95% confidence interval (CI) 1.92-6.45], stress (OR 2.38, 95% CI 1.52-3.71), insomnia (OR 2.31, 95% CI 1.39-3.81), and upset (OR 2.69, 95% CI 1.47-4.95) to a greater extent than men. Outdoor activity was less reported by women (OR 0.35, 95% CI 0.14-0.87). No significant sex differences were found in other activities or food and alcohol consumption.

Conclusion

Self-experienced stress and distress were higher among women prior to MI compared with men. Understanding sex perspectives in acute triggers may help us find preventive strategies and reduce the excess numbers of MI.