Reducing Emotional Distress Improves Prognosis in Coronary Heart Disease

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Abstract
Background The impact of treating emotional distress on prognosis in coronary heart disease (CHD) has not been documented convincingly. We tested the hypothesis that treatment-related changes in emotional distress may explain the beneficial effect of rehabilitation on prognosis. Methods and Results In this nonrandomized clinical trial, 150 men with CHD participated in rehabilitation (n=78) or received standard medical care (n=72). There were no differences between rehabilitation and control patients with regard to left ventricular ejection fraction (LVEF) or standard care. End points were reduction in distress after 3 months and mortality after 9 years. At the end of the 3-month trial, 64 patients (43%) reported improvement and 22 (15%) reported deterioration in negative affect. Rehabilitation patients improved more ( P =0.004) and deteriorated less ( P =0.001) than control patients; rehabilitation was effective in reducing distress. After 9 years of follow-up, 15 patients had died (13 cardiac and 2 cancer deaths). Mortality was associated with LVEF ≤50% ( P =0.038) and deterioration in negative affect ( P =0.007). Rate of death was 17% (12/72) for control patients versus 4% (3/78) for rehabilitation patients ( P =0.009); rehabilitation was effective in reducing mortality. LVEF ≤50% (OR 3.2; 95% CI 1.1 to 9.8; P =0.041) and rehabilitation (OR 0.2; 95% CI 0.1 to 0.7; P =0.016) were independent predictors of mortality. Rehabilitation warded off the deleterious effect of deterioration in negative affect on prognosis. Conclusions Deterioration in negative affect is associated with a high long-term mortality risk. Warding off deterioration in negative affect is a mechanism that may explain the beneficial effect of comprehensive rehabilitation on prognosis in patients with CHD.