Psychosocial aspects in cardiac rehabilitation: From theory to practice. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology
Open accessAbstract
A large body of empirical research shows that psychosocial risk factors (PSRFs) such as low socio-economic status, social isolation, stress, type-D personality, depression and anxiety increase the risk of incident coronary heart disease (CHD) and also contribute to poorer health-related quality of life (HRQoL) and prognosis in patients with established CHD. PSRFs may also act as barriers to lifestyle changes and treatment adherence and may moderate the effects of cardiac rehabilitation (CR). Furthermore, there appears to be a bidirectional interaction between PSRFs and the cardiovascular system. Stress, anxiety and depression affect the cardiovascular system through immune, neuroendocrine and behavioural pathways. In turn, CHD and its associated treatments may lead to distress in patients, including anxiety and depression. In clinical practice, PSRFs can be assessed with single-item screening questions, standardised questionnaires, or structured clinical interviews. Psychotherapy and medication can be considered to alleviate any PSRF-related symptoms and to enhance HRQoL, but the evidence for a definite beneficial effect on cardiac endpoints is inconclusive. A multimodal behavioural intervention, integrating counselling for PSRFs and coping with illness should be included within comprehensive CR. Patients with clinically significant symptoms of distress should be referred for psychological counselling or psychologically focused interventions and/or psychopharmacological treatment. To conclude, the success of CR may critically depend on the interdependence of the body and mind and this interaction needs to be reflected through the assessment and management of PSRFs in line with robust scientific evidence, by trained staff, integrated within the core CR team.
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Clinical and subthreshold depression or anxiety increase risk of hospitalisation.
“Both a clinical diagnosis and subthreshold levels – often undetected – comprise barriers for lifestyle changes, increase risk of non-adherence, refusal or dropout from cardiac rehabilitation (CR), hospitalisation, and premature death [4–6].”
From Efficacy and cost-effectiveness of a therapist-assisted web-based intervention for depression and anxiety in patients with ischemic heart disease attending cardiac rehabilitation [eMindYourHeart trial]: a randomised controlled trial protocol (2021) · cites this paper as [5]
The Negative affect section (page unavailable) links depression immediately before and after bypass surgery to higher re-hospitalisation rates. It does not establish increased hospitalisation risk for anxiety or specifically for subthreshold depression or anxiety, so the claim is broader than the evidence. (LLM, conf=0.86)
Experimental — accuracy not yet measuredDepression is associated with risk of non-adherence to cardiac rehabilitation and dropout.
“Depression is associated with risk of non-adherence to cardiac rehabilitation (CR) and dropout, inadequate risk factor management, poor quality of life (QoL), increased healthcare costs and premature death.”
Clinical and subthreshold depression or anxiety increase risk of premature death.
“Both a clinical diagnosis and subthreshold levels – often undetected – comprise barriers for lifestyle changes, increase risk of non-adherence, refusal or dropout from cardiac rehabilitation (CR), hospitalisation, and premature death [4–6].”
Clinical and subthreshold depression or anxiety comprise barriers for lifestyle changes.
“Both a clinical diagnosis and subthreshold levels – often undetected – comprise barriers for lifestyle changes, increase risk of non-adherence, refusal or dropout from cardiac rehabilitation (CR), hospitalisation, and premature death [4–6].”
Anxiety and depression are barriers for participation and adherence to cardiac rehabilitation.
“Numerous barriers for participation and adherence exist and include person-related factors (e.g. gender, socio-economic status, health literacy, and comorbidities), factors related to the CR program (e.g. accessibility, proximity to the CR setting) [18], and anxiety and depression [5, 18].”
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- Authors
- Pogosova, N., Saner, H., Pedersen, S. S., Cupples, M. E., McGee, H., Höfer, S., Doyle, F., Schmid, J.-P., von Känel, R., & on behalf of the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation of the European Society of Cardiology
- Affiliations
- Federal Health Center and Department of Internal Disease Prevention , National Research Center for Preventive Medicine, Russia
- University Hospital of Bern (CH)
- University of Southern Denmark (DK)
- Queen's University Belfast (GB)
- Royal College of Surgeons in Ireland (IE)
- Innsbruck Medical University (AT)
- Department of Neurology , Bern University Hospital, Switzerland
- ORCID
- Venue
- European Journal of Preventive Cardiology
- Publisher
- Oxford University Press (OUP)
- Published
- 2015-10-01
- Volume
- 22
- Issue
- 10
- Pages
- 1290-1306
- ISSN
- 2047-4873 (ISSN-L)
- 2047-4881
- OpenAlex
- W2107383633
- Cited by
- 292
- References
- 210
- Citations by year
- 2026: 13 · 2025: 10 · 2024: 26 · 2023: 26 · 2022: 41 · 2021: 24 · 2020: 31 · 2019: 28 · 2018: 27 · 2017: 28 · 2016: 26 · 2015: 9 · 2014: 3
- FWCI
- 15.09
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- European Journal of Preventive Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Bern Open Repository and Information System (University of Bern) (submittedVersion)
- Figshare (submittedVersion, cc-by-nc-sa)
- Research Portal (Queen's University Belfast) (submittedVersion)
- University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion)
- Funders
- Medical Research Council (MR/K023241/1)
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac Health and Mental Health
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Health Sciences › Medicine › Rehabilitation › Stroke Rehabilitation and Recovery
- Keywords
- cardiac rehabilitation, psychosocial risk factors, coronary artery disease, depression, anxiety, social isolation, stress, Type D personality, health-related quality of life, psychotherapy, psychopharmacological treatment, psychological counselling, medication adherence, psychosocial assessment, mind-body problem
- MeSH terms
- Adaptation, Psychological, Cardiology, Cooperative Behavior, Heart Diseases, Humans, Interviews as Topic, Mental Health, Patient Care Team, Predictive Value of Tests, Prognosis, Psychiatric Status Rating Scales, Quality of Life, Surveys and Questionnaires, Risk Factors, Cost of Illness, Consensus, Interdisciplinary Communication
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