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Original Investigation |

Adverse Psychological and Coronary Risk Profiles in Young Patients With Coronary Artery Disease and Benefits of Formal Cardiac Rehabilitation FREE

Carl J. Lavie, MD; Richard V. Milani, MD
[+] Author Affiliations

Author Affiliations: Department of Cardiovascular Diseases, Ochsner Medical Center, New Orleans, La.


Arch Intern Med. 2006;166(17):1878-1883. doi:10.1001/archinte.166.17.1878.
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Published online

Background  Recent data indicate that young patients with coronary artery disease (CAD) have a poor long-term prognosis. Although the benefits of formal cardiac rehabilitation and exercise training programs are well established, most of these data come from middle-aged and older patients.

Methods  We assessed baseline behavioral data, quality of life, and risk profiles in 635 consecutive patients with CAD before and after cardiac rehabilitation and exercise training, and specifically assessed data in 104 young patients (mean ± SD age, 48 ± 6 years; range, 22-54 years) compared with 260 elderly patients (mean ± SD age, 75 ± 3 years; range, 70-85 years).

Results  Compared with older patients, young patients had higher body mass indexes (12.2%, P<.001), total cholesterol–high-density lipoprotein ratio (14.6%, P<.01), and triglycerides level (27.2%, P<.01), and a lower high-density lipoprotein cholesterol level (−8.8%, P=.045). Young patients also had higher scores for anxiety and hostility (51.5% and 94.4%, respectively; P<.001 for both), a considerably higher prevalence of anxiety (27.9% vs 13.5%; P<.01) and hostility (12.5% vs 4.6%; P<.01) symptoms, and slightly more depression symptoms (23.1% vs 18.8%) compared with elderly patients. Following cardiac rehabilitation and exercise training, young patients had improvements in body mass index (−1.7%, P<.01), percentage body fat (−4.4%, P<.001), high-density lipoprotein cholesterol level (10.2%, P<.001), high-sensitivity C-reactive protein level (−33.3%, P<.01), peak oxygen consumption (11.3%, P<.001), resting heart rate (−4.5%, P=.01), and resting systolic pressure (−2.3%, P=.049), and marked improvements in scores for depression (−58.5%), anxiety (−46.0%), hostility (−45.7%), somatization (−33.8%), and quality of life (15.8%) (P<.001 for all). Young patients also had greater than 50% to greater than 80% reductions in the prevalence of anxiety (P<.001), hostility (P<.01), and depression (P<.001).

Conclusion  These data demonstrate the adverse psychological and CAD risk profiles that are present in young patients with CAD following major CAD events, and are consistent with substantial benefit of formal cardiac rehabilitation and exercise training programs in younger adults.

Figures in this Article

Substantial evidence indicates that psychological distress is a significant coronary artery disease (CAD) risk factor and adversely affects recovery after major CAD events.13 Although most of this evidence has focused on the high prevalence of depression in patients with CAD and on depression as a CAD risk factor,36 evidence also indicates that anxiety and hostility are associated with an increase in CAD events.1,715 A psychosocial index comprising many of these behaviors has recently been shown to be an independent risk factor for the development of myocardial infarction.16,17 Moreover, these psychological risk factors have been associated with dyslipidemia, hypertension, obesity, inflammatory biomarkers, coronary calcium and atherosclerosis, and peripheral atherosclerosis.1823

Although elderly persons compose the largest portion of patients with CAD, recent studies2427 suggest that younger patients represent a growing segment of the population with CAD and carry a poor long-term prognosis. Researchers2830 have demonstrated the marked benefits of cardiac rehabilitation and exercise training (CRET) programs in secondary CAD prevention, including benefits on standard CAD risk factors and psychological factors3,5,6,8,1315; however, most of these studies have been performed in middle-aged and older subjects.

The present study determines the baseline psychological and overall CAD risk profiles in many younger patients with CAD and compares them with those of older patients, following a CAD event. We also sought to document the effects of formal phase 2 CRET programs in this young cohort with CAD.

STUDY POPULATION

We studied 635 consecutive patients with CAD who were referred to, attended, and completed phase 2 CRET programs at Ochsner Clinic Foundation in New Orleans, following major CAD events (myocardial infarction, unstable angina, or major coronary revascularization), and we specifically assessed detailed data in 104 young patients with CAD (aged <55 years; mean ± SD age, 48 ± 6 years; age range, 22-54 years; 73.1% male) compared with 260 elderly patients (aged ≥70 years; mean ± SD age, 75 ± 3 years; age range, 70-85 years; 75.4% male). We also report baseline data in 52 young patients (aged <55 years; mean ± SD age, 48 ± 5 years; age range, 23-54 years; 76.9% male) and 68 older patients (aged ≥70 years; mean ± SD age, 76 ± 4 years; age range, 70-88 years; 67.2% male) who either enrolled and did not attend formal CRET or dropped out during the program. All patients completed validated questionnaires before and after the CRET program. This study was approved by the institutional review board of Ochsner Clinic Foundation.

BEHAVIORAL TESTING

The Kellner Symptom Questionnaire has been validated to assess behavioral characteristics, including symptoms of depression, anxiety, hostility, and somatization, with a lower score indicating a more favorable behavioral trait (manual of the symptom questionnaire available on request; R. P. Kellner, MD, PhD, written and oral communication, 1986).31,32 The Medical Outcomes Study 36-Item Short-Form Health Survey was used to assess the total quality-of-life score using a standardized coding algorithm, with a higher score indicating a more favorable quality of life.33 Based on prior studies of mean scores in healthy subjects (R. P. Kellner, MD, PhD, unpublished data, January 1987, normal scores (scaled score between 1 and 2 SDs above the mean) for anxiety and hostility are 7 or less; and for depression, less than 7. Therefore, we chose 8 or higher as a cutoff to indicate anxiety and hostility symptoms and 7 or higher for depression symptoms. In addition, we assessed the prevalence of these behavioral symptoms in the younger vs the older patients.

PROTOCOL

The protocol, data collection, and statistical analyses were performed as described previously.3,5,6,8,1315 The CRET program generally lasted 12 weeks and consisted of 36 educational and exercise sessions, with exercise sessions consisting of 10 minutes of warm-up, calisthenics, and stretching, followed by 30 to 45 minutes of continuous aerobic and dynamic exercise and light isometrics, and approximately 5 to 10 minutes of cooldown. Exercise intensity was prescribed close to the anaerobic or ventilatory threshold obtained by baseline cardiopulmonary stress testing and 10 to 15 beats/min below the level of any exercise-induced or silent myocardial ischemia. In addition, we encouraged patients to perform 1 to 3 exercise sessions per week at home and periodically adjusted exercise prescription to encourage a gradual improvement in overall exercise performance. Besides the exercise portion of the program, daily lectures and group sessions were directed by a licensed nurse, an exercise physiologist, or a dietitian, emphasizing all aspects of CAD and prevention. Although patients and their significant others were taught about behavioral factors, stress, and sexual function and could ask questions in all of these areas, we did not routinely provide individual attention to these areas, including individual counseling directed at high-risk patients with adverse behavioral characteristics, including anxiety, hostility or anger management, and depression.

At baseline (2-6 weeks after the major CAD event) and again 1 week after the CRET, we obtained several measurements, including height, weight, body mass index, percentage body fat (by the sum of the skinfold method), fasting plasma lipids level, and cardiopulmonary exercise data.

STATISTICAL ANALYSES

Continuous variables were expressed as mean ± SD. Two-sample t tests and analysis of variance were used to assess differences in baseline characteristics and CRET data between young and older patients, and baseline characteristics were also compared between those completing and those not completing the CRET program. Changes between baseline and post-CRET data were compared using a paired t test and χ2 analysis, with P<.05 used to determine statistical significance. All data analyses were performed with computer software (StatView; SAS Institute Inc, Cary, NC) on a computer system (Macintosh II; Apple Computers, Inc, Cupertino, Calif).

The baseline characteristics of the study cohort are demonstrated in Table 1. Young CRET patients comprised 16.4% of patients completing the formal program and had a significantly higher body mass index (12.2%), total cholesterol–high-density lipoprotein cholesterol ratio (14.6%), and triglycerides level (27.2%), and lower levels of high-density lipoprotein cholesterol (−8.8%) and resting systolic blood pressure (−7.1%), than elderly patients. As expected, young patients had considerably higher levels of peak oxygen consumption (V.O2) (45.7%). In addition, young patients had higher scores for depression (24.2%), hostility (94.4%), and anxiety (51.5%) than did elderly patients and a slightly higher prevalence of depression symptoms and a significantly higher prevalence of anxiety and hostility symptoms (P<.01 for both) than did older patients (Figure). Although many of the baseline characteristics of young patients not completing CRET were slightly more adverse than the characteristics of those completing CRET, only the difference in peak V.O2 was statistically significant (P=.038). Likewise, elderly patients not completing CRET had significantly lower peak V.O2 and higher anxiety scores (P=.042 for both) compared with elderly patients completing CRET.

Place holder to copy figure label and caption
Figure.

Prevalence of adverse behavioral characteristics in young (mean ± SD age, 48 ± 6 years) and elderly (mean ± SD age, 75 ± 3 years) patients with coronary artery disease at baseline. The asterisk indicates P<.01.

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Table Graphic Jump LocationTable 1. Baseline Characteristics of Young and Older Patients With Coronary Artery Disease, Completing and Not Completing Formal Cardiac Rehabilitation

Following the CRET programs (Table 2), the young patients had significant improvements in many variables, including obesity indexes, high-density lipoprotein level, high-sensitivity C-reactive protein level, peak V.O2, resting heart rate, and resting systolic pressure. In addition, young patients had marked improvements in scores for anxiety, depression, hostility, somatization, and quality of life.

Table Graphic Jump LocationTable 2. Risk Factor Changes Noted in 104 Young Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*

Likewise, elderly patients completing CRET also demonstrated significant improvements in most variables studied (Table 3). Although most of the relative improvements following CRET were statistically similar in the younger and older patients, the young patients had significantly greater improvements in body mass index (−1.7% vs −0.4%; P=.03) and hostility score (−45.7% vs −16.7%; P=.05) and a trend for greater improvement in peak V.O2 (11.3% vs 7.1%; P=.09) compared with the elderly patients. Fasting glucose level decreased minimally following CRET in younger patients and increased significantly in older patients; these relative differences were also statistically significant (P = .03).

Table Graphic Jump LocationTable 3. Risk Factor Changes Noted in 260 Older Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*

Following CRET, there was a marked decrease in the prevalence of anxiety symptoms (P<.001), with the prevalence of anxiety being equal after CRET in younger and older patients (Table 4). Likewise, the young patients had a greater than 50% decrease in the prevalence of hostility symptoms and a greater than 80% decrease in depression symptoms following CRET.

Table Graphic Jump LocationTable 4. Effects of Cardiac Rehabilitation and Exercise Training Programs on Symptoms of Anxiety, Hostility,and Depression in Young and Older Patients With Coronary Artery Disease

There are 3 important findings from this investigation. First, young patients compose a significant segment of the population with CAD completing formal CRET programs. Second, young patients with CAD are characterized by a higher degree of psychological distress, obesity, and dyslipidemia. Third, these adverse characteristics substantially improved following formal phase 2 CRET programs.

The importance of behavioral and psychological risk factors in the pathogenesis and expression of atherosclerosis and CAD has been controversial, although data support the concept that various factors, including depression, anxiety, long-term life stress, and hostility or anger, contribute significantly to the pathogenesis of atherosclerosis and the development of major CAD events.123 Probably most of the early evidence focused on depression as a major risk factor.36 Moreover, several studies34,35 have demonstrated poor recovery from depression in patients with CAD following major events. In addition to depression, Friedman and Rosenman36 have defined persons who exhibited an emotional syndrome characterized by a continuously harrying sense of time, urgency, aggressiveness, ambitiousness, competitive drive, and easily aroused free-floating hostility as having type A behavior, and some studies7,912 have demonstrated up to a 4-fold increased incidence of clinical CAD in these patients. Recently, hostility has been linked with metabolic syndrome and an increased risk of mortality, especially in younger patients.26,27 The role of anxiety with CAD has been most controversial, although several large-scale community-based studies1,14,37 have demonstrated a link between anxiety and cardiac, especially sudden, death. Most important, the INTERHEART study, which included 29 972 subjects from 52 countries, found that psychosocial factors were a strong independent risk factor for myocardial infarction, composing nearly one third of the population's attributable risk for myocardial infarction.16,17

Considerable evidence has demonstrated the substantial benefits of formal phase 2 CRET, including beneficial effects in patients with adverse psychological risk factors.3,5,6,8,1315 In a recent randomized trial, exercise training decreased depressive symptoms as effectively as antidepressant medication in patients with clinical depression.38,39 However, in the field of CRET, most studies have focused on middle-aged or older groups of patients, whereas our study focused on the adverse psychological and overall CAD risk profiles in mostly younger patients following major CAD events. Not only do younger patients experience more obesity and dyslipidemia than do older patients, we also found that the younger patients have a more adverse psychological risk profile, especially hostility and anxiety, that may contribute to the relatively poor prognosis that has been noted in younger patients with CAD.2426

The mechanism by which psychological and behavioral risk factors may cause premature CAD is unclear, but is likely multifactorial, including worsening atherosclerosis risk factors, as suggested by our data, and may directly contribute to atherosclerosis,8,1820 enhanced platelet reactivity,40 inflammation,20 increased catecholamines,41 and coronary vasoreactivity and vasoconstriction,42,43 all of which may increase the risk of CAD events. Anxiety may increase sympathetic activity, reduce vagal tone, and increase the risk of malignant ventricular arrhythmias, all of which may increase the risk of sudden cardiac death.14,37

The improvements of psychological risk factors noted in our patients following formal CRET are also probably multifactorial. Cardiac rehabilitation is centered around progressive exercise training, which is known to exert salutary effects on certain emotions and autonomic tone.5,13,44,45 We have demonstrated that CRET not only improves variables of blood rheology but also has significant benefits for the autonomic nervous system that may be related to the benefits obtained in psychological and behavioral factors.46,47 Recent data also emphasize the beneficial effects of exercise on cognitive function and brain plasticity.48 The education of the patient and the patient's significant other may also be important by increasing understanding of the underlying disease process and its manifestations, thus empowering patients to modify their own recovery. This process of patients becoming more involved in their own health care is called “information involvement,”5,8,49 which may enhance the coping and social and emotional recovery process. In addition, socialization and bonding with other patients who are at various stages of recovery and CRET probably contribute to the favorable effects seen on their adverse psychological risk factors.8,13,50 Previously, a meta-analysis by Linden et al51 of 23 randomized controlled trials that evaluated the additional impact of psychosocial treatment of rehabilitation demonstrated that this therapy improves psychological distress and biological risk factors (heart rate, systolic pressure, and lipid levels) and reduces major morbidity and mortality. We believe that the benefits obtained in our program are noteworthy, especially because this was accomplished through group sessions for the entire CRET population and individual counseling directed at high-risk behaviors was not included.

Several potential study limitations are worth emphasizing. First, we did not include data on a formal control population. However, in several other studies8,52 from our CRET programs, including a total of 249 control patients (mostly younger) who did not attend CRET, we identified no improvements over time in the overall CAD risk profile, including behavioral scores and the prevalence of depression, anxiety, and hostility symptoms, which is consistent with other studies34,35 demonstrating poor spontaneous recovery from depression in patients following major CAD events. Therefore, all of this evidence suggests that the improvements noted following CRET are likely secondary to the intervention introduced and not because of chance or regression to the mean. In addition, our patients received dietary recommendations, including increasing consumption of ω-3 fatty acids as part of a Mediterranean-type diet, which may have an affect on psychological factors.53 However, patients with and without high psychological risk factors received similar dietary advice, and we did not assess dietary compliance or blood levels of ω-3 fatty acids. Finally, although the scale that we used for the assessment of behavioral characteristics has been validated,31,32 its prognostic impact has not been as validated as some other scales commonly used. Nevertheless, our prevalence rates of adverse psychological factors, particularly depression, are quite similar to rates published by others using other validated scales.2,4,3437

We believe that our data support the markedly abnormal overall psychological and CAD risk profiles in younger patients with CAD and the substantial benefits that occur following formal CRET programs. Although many young patients with CAD have obstacles to CRET programs, including needing to return to the workforce and family obligations, these data support the need to emphasize formal CRET for their long-term secondary CAD prevention, including routine referral and strongly encouraging young patients to attend and complete these programs.

Correspondence: Carl J. Lavie, MD, Department of Cardiovascular Diseases, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121 (clavie@ochsner.org).

Accepted for Publication: May 31, 2006.

Author Contributions: Drs Lavie and Milani had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Financial Disclosure: None reported.

Previous Presentation: This study was presented in part as a podium presentation to the Annual Scientific Assembly of the American Heart Association; November 8, 2004; New Orleans, La.

Rozanski  ABlumenthal  JADavidson  KWSaab  PGKubzansky  L The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol 2005;45637- 651
Link to Article
Allison  TGWilliams  DEMiller  TD  et al.  Medical and economic costs of psychological distress in patients with coronary artery disease. Mayo Clin Proc 1995;70734- 742
PubMed Link to Article
Milani  RVLavie  CJ Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events. Am J Med 1996;100517- 523
PubMed Link to Article
Frasure-Smith  NLesperance  FTalajic  M Depression following myocardial infarction: impact on 6-month survival. JAMA 1993;2701819- 1825[published correction appears in JAMA. 1994;271:1082]
PubMed Link to Article
Milani  RVLavie  CJCassidy  MM Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events. Am Heart J 1996;132726- 732
PubMed Link to Article
Milani  RVLavie  CJ Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. Am J Cardiol 1998;811233- 1236
PubMed Link to Article
Rosenman  RHBrand  RJJenkins  DFriedman  MStraus  RWurm  M Coronary heart disease in Western Collaborative Group Study: final follow-up experience of 8½ years. JAMA 1975;233872- 877
PubMed Link to Article
Lavie  CJMilani  RV Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training. Mayo Clin Proc 2005;80335- 342
PubMed Link to Article
Jenkins  CD Medical progress: recent evidence supporting psychologic and social risk factors for coronary disease (first of two parts). N Engl J Med 1976;294987- 994
PubMed Link to Article
Haynes  SGFeinleib  MKannel  WB The relationship of psychosocial factors to coronary heart disease in the Framingham Study, III: eight-year incidence of coronary heart disease. Am J Epidemiol 1980;11137- 58
PubMed
Friedman  MThoresen  CEGill  JJ  et al.  Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project. Am Heart J 1986;112653- 665
Link to Article
Barefoot  JCDahlstrom  WGWilliams  RB  Jr Hostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians. Psychosom Med 1983;4559- 63
PubMed Link to Article
Lavie  CJMilani  RV Effects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility. Mayo Clin Proc 1999;74959- 966
PubMed Link to Article
Lavie  CJMilani  RV Prevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training. Am J Cardiol 2004;93336- 339
PubMed Link to Article
Lavie  CVMilani  RV Impact of aging on hostility in coronary patients and effects of cardiac rehabilitation and exercise training in elderly persons. Am J Geriatr Cardiol 2004;13125- 130
Link to Article
Yusuf  SHawken  SOunpuu  S  et al. INTERHEART Study Investigators, Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364937- 952
Link to Article
Rosengren  AHawken  SOunpuu  S  et al. INTERHEART Investigators, Association of psychosocial risk factors with risk of acute myocardial infarction in 11,119 cases and 13,648 controls from 52 countries (the INTERHEART study): case-control study. Lancet 2004;364953- 962
PubMed Link to Article
Rutledge  TReis  SEOlson  M  et al.  Psychosocial variables are associated with atherosclerosis risk factors among women with chest pain: the WISE study. Psychosom Med 2001;63282- 288
PubMed Link to Article
Yan  LLLiu  KMatthews  KADaviglus  MLFerguson  TFKiefe  CI Psychosocial factors and risk of hypertension: the Coronary Artery Risk Development in Young Adults (CARDIA) study. JAMA 2003;2902138- 2148
PubMed Link to Article
Suarez  EC Plasma interleukin-6 is associated with psychological coronary risk factors: moderation by use of multivitamin supplements. Brain Behav Immun 2003;17296- 303
PubMed Link to Article
Iribarren  CSidney  SBild  DE  et al.  Association of hostility with coronary artery calcification in young adults: the CARDIA study. JAMA 2000;2832546- 2551
PubMed Link to Article
Knox  SSAdelman  AEllison  RC  et al.  Hostility, social support, and carotid artery atherosclerosis in the National Heart, Lung, and Blood Institute Family Heart Study. Am J Cardiol 2000;861086- 1089
PubMed Link to Article
Whiteman  MCDeary  IJFowkes  FG Personality and social predictors of atherosclerotic progression: Edinburgh Artery Study. Psychosom Med 2000;62703- 714
PubMed Link to Article
Cole  JHMiller  JI  IIISperling  LSWeintraub  WS Long-term follow-up of coronary artery disease presenting in young adults. J Am Coll Cardiol 2003;41521- 528
PubMed Link to Article
Awad-Elkarim  AABagger  JPAlbers  CJSkinner  JSAdams  PCHall  RJ A prospective study of long term prognosis in young myocardial infarction survivors: the prognostic value of angiography and exercise testing. Heart 2003;89843- 847
PubMed Link to Article
Todaro  JFAndrea  CNiaura  RSpio  A  IIIWard  KDRoytberg  A Combined effect of the metabolic syndrome and hostility on the incidence of myocardial infarction (the Normative Aging Study). Am J Cardiol 2005;96221- 226
PubMed Link to Article
Boyle  SHWilliams  RBMark  DBBrummet  BHSiegler  ICBarefoot  JC Hostility, age, and mortality in a sample of cardiac patients. Am J Cardiol 2005;9664- 66
PubMed Link to Article
Ades  PA Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med 2001;345892- 902
PubMed Link to Article
Wenger  NKFroehlicher  ESSmith  LK  et al.  Cardiac Rehabilitation: Clinical Practice Guidelines.  Rockville, Md Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute1995;AHCPR publication 96-0672
Witt  BJJacobsen  SJWeston  SA  et al.  Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol 2004;44988- 996
Link to Article
Kellner  R A symptom questionnaire. J Clin Psychiatry 1987;48268- 274
PubMed
Kellner  RSheffield  BJ A self-rating scale of distress. Psychol Med 1973;388- 100
PubMed Link to Article
Stewart  ALGreenfield  SHays  RD  et al.  Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study (published correction appears in JAMA. 1989;262:2542). JAMA 1989;262907- 913
Link to Article
Stern  MJPascale  LAckerman  A Life adjustment post-myocardial infarction: determining predictive variables. Arch Intern Med 1977;1371680- 1685
PubMed Link to Article
Ladwig  KHRoll  GBreithardt  GBudde  TBorggrefe  M Post-infarction depression and incomplete recovery 6 months after acute myocardial infarction. Lancet 1994;34320- 23
PubMed Link to Article
Friedman  MRosenman  RH Association of specific overt behavior pattern with blood and cardiovascular findings: blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease. JAMA 1959;1691286- 1296
Link to Article
Kawachi  ISparrow  DVokonas  PSWeiss  ST Symptoms of anxiety and risk of coronary heart disease: the Normative Aging Study. Circulation 1994;902225- 2229
PubMed Link to Article
Blumenthal  JABabyak  MAMoore  KA  et al.  Effects of exercise training on older patients with major depression. Arch Intern Med 1999;1592349- 2356
PubMed Link to Article
Babyak  MBlumenthal  JAHerman  S  et al.  Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med 2000;62633- 638
PubMed Link to Article
Markovitz  JH Hostility is associated with increased platelet activation in coronary heart disease. Psychosom Med 1998;60586- 591
PubMed Link to Article
Fukudo  SLane  JDAnderson  NB  et al.  Accentuated vagal antagonism of β-adrenergic effects on ventricular repolarization: evidence of weaker antagonism in hostile type A men. Circulation 1992;852045- 2053
Link to Article
Chang  PPFord  DEMeoni  LAWang  NYKlag  MJ Anger in young men and subsequent premature cardiovascular disease: the precursors study. Arch Intern Med 2002;162901- 906
PubMed Link to Article
Boltwood  MDTaylor  CBBurke  MBGrogin  JGiacomini  J Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments. Am J Cardiol 1993;721361- 1365
PubMed Link to Article
Blumenthal  JAFredrikson  MKuhn  CMUlmer  RLWalsh-Riddle  MAppelbaum  M Aerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia. Am J Cardiol 1990;6593- 98
Link to Article
Blumenthal  JAWilliams  RSNeedels  TLWallace  AG Psychological changes accompany aerobic exercise in healthy middle-aged adults. Psychosom Med 1982;44529- 536
Link to Article
Church  TSLavie  CJMilani  RVKirby  GS Improvements in blood rheology after cardiac rehabilitation and exercise training in patients with coronary heart disease. Am Heart J 2002;143349- 355
PubMed Link to Article
Kalapura  TLavie  CJJaffrani  WChilakamarri  VMilani  RV Effects of cardiac rehabilitation and exercise training on indexes of dispersion of ventricular repolarization in patients after acute myocardial infarction. Am J Cardiol 2003;92292- 294
PubMed Link to Article
McAuley  EKramer  AFColcombe  SJ Cardiovascular fitness and neurocognitive function in older adults: a brief overview. Brain Behav Immun 2004;18214- 220
PubMed Link to Article
Krantz  DSBaum  AWideman  M Assessment of pREFERENCES for self-treatment and information in health care. J Pers Soc Psychol 1980;39977- 990
PubMed Link to Article
Kulik  JAMahler  HI Social support and recovery from surgery. Health Psychol 1989;8221- 238
PubMed Link to Article
Linden  WStossel  CMaurice  J Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med 1996;156745- 752
PubMed Link to Article
Milani  RVLavie  CJMehra  MR Reduction in C-reactive protein through cardiac rehabilitation and exercise training. J Am Coll Cardiol 2004;431056- 1061
PubMed Link to Article
Severus  WELittman  ABStoll  AL Omega-3 fatty acids, homocysteine, and the increased risk of cardiovascular mortality in major depressive disorder. Harv Rev Psychiatry 2001;9280- 293
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure.

Prevalence of adverse behavioral characteristics in young (mean ± SD age, 48 ± 6 years) and elderly (mean ± SD age, 75 ± 3 years) patients with coronary artery disease at baseline. The asterisk indicates P<.01.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics of Young and Older Patients With Coronary Artery Disease, Completing and Not Completing Formal Cardiac Rehabilitation
Table Graphic Jump LocationTable 2. Risk Factor Changes Noted in 104 Young Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*
Table Graphic Jump LocationTable 3. Risk Factor Changes Noted in 260 Older Patients With Coronary Artery Disease Following Formal Cardiac Rehabilitation*
Table Graphic Jump LocationTable 4. Effects of Cardiac Rehabilitation and Exercise Training Programs on Symptoms of Anxiety, Hostility,and Depression in Young and Older Patients With Coronary Artery Disease

References

Rozanski  ABlumenthal  JADavidson  KWSaab  PGKubzansky  L The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol 2005;45637- 651
Link to Article
Allison  TGWilliams  DEMiller  TD  et al.  Medical and economic costs of psychological distress in patients with coronary artery disease. Mayo Clin Proc 1995;70734- 742
PubMed Link to Article
Milani  RVLavie  CJ Behavioral differences and effects of cardiac rehabilitation in diabetic patients following cardiac events. Am J Med 1996;100517- 523
PubMed Link to Article
Frasure-Smith  NLesperance  FTalajic  M Depression following myocardial infarction: impact on 6-month survival. JAMA 1993;2701819- 1825[published correction appears in JAMA. 1994;271:1082]
PubMed Link to Article
Milani  RVLavie  CJCassidy  MM Effects of cardiac rehabilitation and exercise training programs on depression in patients after major coronary events. Am Heart J 1996;132726- 732
PubMed Link to Article
Milani  RVLavie  CJ Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease. Am J Cardiol 1998;811233- 1236
PubMed Link to Article
Rosenman  RHBrand  RJJenkins  DFriedman  MStraus  RWurm  M Coronary heart disease in Western Collaborative Group Study: final follow-up experience of 8½ years. JAMA 1975;233872- 877
PubMed Link to Article
Lavie  CJMilani  RV Prevalence of hostility in young coronary artery disease patients and effects of cardiac rehabilitation and exercise training. Mayo Clin Proc 2005;80335- 342
PubMed Link to Article
Jenkins  CD Medical progress: recent evidence supporting psychologic and social risk factors for coronary disease (first of two parts). N Engl J Med 1976;294987- 994
PubMed Link to Article
Haynes  SGFeinleib  MKannel  WB The relationship of psychosocial factors to coronary heart disease in the Framingham Study, III: eight-year incidence of coronary heart disease. Am J Epidemiol 1980;11137- 58
PubMed
Friedman  MThoresen  CEGill  JJ  et al.  Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project. Am Heart J 1986;112653- 665
Link to Article
Barefoot  JCDahlstrom  WGWilliams  RB  Jr Hostility, CHD incidence, and total mortality: a 25-year follow-up study of 255 physicians. Psychosom Med 1983;4559- 63
PubMed Link to Article
Lavie  CJMilani  RV Effects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility. Mayo Clin Proc 1999;74959- 966
PubMed Link to Article
Lavie  CJMilani  RV Prevalence of anxiety in coronary patients with improvement following cardiac rehabilitation and exercise training. Am J Cardiol 2004;93336- 339
PubMed Link to Article
Lavie  CVMilani  RV Impact of aging on hostility in coronary patients and effects of cardiac rehabilitation and exercise training in elderly persons. Am J Geriatr Cardiol 2004;13125- 130
Link to Article
Yusuf  SHawken  SOunpuu  S  et al. INTERHEART Study Investigators, Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004;364937- 952
Link to Article
Rosengren  AHawken  SOunpuu  S  et al. INTERHEART Investigators, Association of psychosocial risk factors with risk of acute myocardial infarction in 11,119 cases and 13,648 controls from 52 countries (the INTERHEART study): case-control study. Lancet 2004;364953- 962
PubMed Link to Article
Rutledge  TReis  SEOlson  M  et al.  Psychosocial variables are associated with atherosclerosis risk factors among women with chest pain: the WISE study. Psychosom Med 2001;63282- 288
PubMed Link to Article
Yan  LLLiu  KMatthews  KADaviglus  MLFerguson  TFKiefe  CI Psychosocial factors and risk of hypertension: the Coronary Artery Risk Development in Young Adults (CARDIA) study. JAMA 2003;2902138- 2148
PubMed Link to Article
Suarez  EC Plasma interleukin-6 is associated with psychological coronary risk factors: moderation by use of multivitamin supplements. Brain Behav Immun 2003;17296- 303
PubMed Link to Article
Iribarren  CSidney  SBild  DE  et al.  Association of hostility with coronary artery calcification in young adults: the CARDIA study. JAMA 2000;2832546- 2551
PubMed Link to Article
Knox  SSAdelman  AEllison  RC  et al.  Hostility, social support, and carotid artery atherosclerosis in the National Heart, Lung, and Blood Institute Family Heart Study. Am J Cardiol 2000;861086- 1089
PubMed Link to Article
Whiteman  MCDeary  IJFowkes  FG Personality and social predictors of atherosclerotic progression: Edinburgh Artery Study. Psychosom Med 2000;62703- 714
PubMed Link to Article
Cole  JHMiller  JI  IIISperling  LSWeintraub  WS Long-term follow-up of coronary artery disease presenting in young adults. J Am Coll Cardiol 2003;41521- 528
PubMed Link to Article
Awad-Elkarim  AABagger  JPAlbers  CJSkinner  JSAdams  PCHall  RJ A prospective study of long term prognosis in young myocardial infarction survivors: the prognostic value of angiography and exercise testing. Heart 2003;89843- 847
PubMed Link to Article
Todaro  JFAndrea  CNiaura  RSpio  A  IIIWard  KDRoytberg  A Combined effect of the metabolic syndrome and hostility on the incidence of myocardial infarction (the Normative Aging Study). Am J Cardiol 2005;96221- 226
PubMed Link to Article
Boyle  SHWilliams  RBMark  DBBrummet  BHSiegler  ICBarefoot  JC Hostility, age, and mortality in a sample of cardiac patients. Am J Cardiol 2005;9664- 66
PubMed Link to Article
Ades  PA Cardiac rehabilitation and secondary prevention of coronary heart disease. N Engl J Med 2001;345892- 902
PubMed Link to Article
Wenger  NKFroehlicher  ESSmith  LK  et al.  Cardiac Rehabilitation: Clinical Practice Guidelines.  Rockville, Md Agency for Health Care Policy and Research and the National Heart, Lung, and Blood Institute1995;AHCPR publication 96-0672
Witt  BJJacobsen  SJWeston  SA  et al.  Cardiac rehabilitation after myocardial infarction in the community. J Am Coll Cardiol 2004;44988- 996
Link to Article
Kellner  R A symptom questionnaire. J Clin Psychiatry 1987;48268- 274
PubMed
Kellner  RSheffield  BJ A self-rating scale of distress. Psychol Med 1973;388- 100
PubMed Link to Article
Stewart  ALGreenfield  SHays  RD  et al.  Functional status and well-being of patients with chronic conditions: results from the Medical Outcomes Study (published correction appears in JAMA. 1989;262:2542). JAMA 1989;262907- 913
Link to Article
Stern  MJPascale  LAckerman  A Life adjustment post-myocardial infarction: determining predictive variables. Arch Intern Med 1977;1371680- 1685
PubMed Link to Article
Ladwig  KHRoll  GBreithardt  GBudde  TBorggrefe  M Post-infarction depression and incomplete recovery 6 months after acute myocardial infarction. Lancet 1994;34320- 23
PubMed Link to Article
Friedman  MRosenman  RH Association of specific overt behavior pattern with blood and cardiovascular findings: blood cholesterol level, blood clotting time, incidence of arcus senilis, and clinical coronary artery disease. JAMA 1959;1691286- 1296
Link to Article
Kawachi  ISparrow  DVokonas  PSWeiss  ST Symptoms of anxiety and risk of coronary heart disease: the Normative Aging Study. Circulation 1994;902225- 2229
PubMed Link to Article
Blumenthal  JABabyak  MAMoore  KA  et al.  Effects of exercise training on older patients with major depression. Arch Intern Med 1999;1592349- 2356
PubMed Link to Article
Babyak  MBlumenthal  JAHerman  S  et al.  Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months. Psychosom Med 2000;62633- 638
PubMed Link to Article
Markovitz  JH Hostility is associated with increased platelet activation in coronary heart disease. Psychosom Med 1998;60586- 591
PubMed Link to Article
Fukudo  SLane  JDAnderson  NB  et al.  Accentuated vagal antagonism of β-adrenergic effects on ventricular repolarization: evidence of weaker antagonism in hostile type A men. Circulation 1992;852045- 2053
Link to Article
Chang  PPFord  DEMeoni  LAWang  NYKlag  MJ Anger in young men and subsequent premature cardiovascular disease: the precursors study. Arch Intern Med 2002;162901- 906
PubMed Link to Article
Boltwood  MDTaylor  CBBurke  MBGrogin  JGiacomini  J Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments. Am J Cardiol 1993;721361- 1365
PubMed Link to Article
Blumenthal  JAFredrikson  MKuhn  CMUlmer  RLWalsh-Riddle  MAppelbaum  M Aerobic exercise reduces levels of cardiovascular and sympathoadrenal responses to mental stress in subjects without prior evidence of myocardial ischemia. Am J Cardiol 1990;6593- 98
Link to Article
Blumenthal  JAWilliams  RSNeedels  TLWallace  AG Psychological changes accompany aerobic exercise in healthy middle-aged adults. Psychosom Med 1982;44529- 536
Link to Article
Church  TSLavie  CJMilani  RVKirby  GS Improvements in blood rheology after cardiac rehabilitation and exercise training in patients with coronary heart disease. Am Heart J 2002;143349- 355
PubMed Link to Article
Kalapura  TLavie  CJJaffrani  WChilakamarri  VMilani  RV Effects of cardiac rehabilitation and exercise training on indexes of dispersion of ventricular repolarization in patients after acute myocardial infarction. Am J Cardiol 2003;92292- 294
PubMed Link to Article
McAuley  EKramer  AFColcombe  SJ Cardiovascular fitness and neurocognitive function in older adults: a brief overview. Brain Behav Immun 2004;18214- 220
PubMed Link to Article
Krantz  DSBaum  AWideman  M Assessment of pREFERENCES for self-treatment and information in health care. J Pers Soc Psychol 1980;39977- 990
PubMed Link to Article
Kulik  JAMahler  HI Social support and recovery from surgery. Health Psychol 1989;8221- 238
PubMed Link to Article
Linden  WStossel  CMaurice  J Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med 1996;156745- 752
PubMed Link to Article
Milani  RVLavie  CJMehra  MR Reduction in C-reactive protein through cardiac rehabilitation and exercise training. J Am Coll Cardiol 2004;431056- 1061
PubMed Link to Article
Severus  WELittman  ABStoll  AL Omega-3 fatty acids, homocysteine, and the increased risk of cardiovascular mortality in major depressive disorder. Harv Rev Psychiatry 2001;9280- 293
PubMed Link to Article

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