title: Reducing emotional distress improves prognosis in coronary heart disease: 9-year mortality in a clinical trial of rehabilitation.
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.
  
  
  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.
authors.affiliation: Department of Clinical Health Psychology, Tilburg University, the Netherlands. j.denollet@kub.nl
authors.forename: J
authors.initials: J
authors.lastname: Denollet
authors.forename: D L
authors.initials: DL
authors.lastname: Brutsaert
mesh_terms: D001530:Belgium; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000150:complications / Q000175:diagnosis* / Q000401:mortality* / Q000628:therapy; D005081:Exercise Therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011379:Prognosis; D011581:Psychological Tests; D018570:Risk Assessment; D012720:Severity of Illness Index; D013315:Stress, Psychological / Q000150:complications / Q000175:diagnosis* / Q000628:therapy*; D013318:Stroke Volume; D015996:Survival Rate; D013995:Time; D016896:Treatment Outcome; D016277:Ventricular Function, Left