title: Significance of Comorbid Psychological Stress and Depression on Outcomes After Cardiac Rehabilitation.
abstract: BACKGROUND
  Depression is associated with increased mortality in stable coronary heart disease. Cardiac rehabilitation and exercise training has been shown to decrease depression, psychological stress, and mortality after a coronary heart disease event. The presence of depression at completion of cardiac rehabilitation and exercise training is associated with increased mortality. However, it is unknown if depression with comorbid psychological risk factors such as anxiety or hostility confers an additional mortality disadvantage. We evaluated the mortality effect of anxiety and hostility on depression after cardiac rehabilitation and exercise training.
  
  
  METHODS
  We studied 1150 patients with coronary heart disease following major coronary heart disease events who had completed formal cardiac rehabilitation and exercise training. Using Kellner questionnaires, stress levels were measured in 1 of 3 domains: anxiety, hostility, and depression (with an aggregated overall psychological stress score) and divided into 3 groups: nondepressed (n = 1072), depression alone (n = 18), and depression with anxiety or hostility (n = 60). Subjects were analyzed for all-cause mortality over 161 months of follow-up (mean 6.4 years) by National Death Index.
  
  
  RESULTS
  Depression after cardiac rehabilitation was not common (6.8%; mortality 20.8%) but when present, frequently associated with either anxiety or hostility (77% of depressed patients; mortality 22.0%). After adjustment for age, sex, ejection fraction, and baseline peak oxygen consumption, depression alone (hazard ratio [HR] 1.73, P = .04), as well as depression with comorbid psychological stress, was associated with higher mortality (HR 1.98, P = .03). Furthermore, our data showed an increased mortality when both anxiety and hostility were present in addition to depression after cardiac rehabilitation (HR 2.41, P = .04).
  
  
  CONCLUSIONS
  After cardiac rehabilitation, depression, when present, is usually associated with other forms of psychological stress, which confers additional mortality. More measures are needed to address psychological stress after cardiac rehabilitation.
authors.affiliation: Graduate Medical Education Department, Ocala Regional Medical Center, Fla.
authors.forename: Sergey
authors.initials: S
authors.lastname: Kachur
authors.affiliation: Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, La.
authors.forename: Arthur R
authors.initials: AR
authors.lastname: Menezes
authors.affiliation: Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, La.
authors.forename: Alban
authors.initials: A
authors.lastname: De Schutter
authors.affiliation: Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, La.
authors.forename: Richard V
authors.initials: RV
authors.lastname: Milani
authors.affiliation: Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Institute, Ochsner Clinical School - The University of Queensland School of Medicine, New Orleans, La. Electronic address: clavie@ochsner.org.
authors.forename: Carl J
authors.initials: CJ
authors.lastname: Lavie
mesh_terms: D000368:Aged; D001007:Anxiety / Q000453:epidemiology / Q000401:mortality / Q000503:physiopathology; D000072038:Cardiac Rehabilitation / Q000523:psychology* / Q000706:statistics & numerical data; D015897:Comorbidity; D003327:Coronary Disease / Q000401:mortality / Q000523:psychology* / Q000534:rehabilitation; D003863:Depression / Q000453:epidemiology / Q000401:mortality / Q000503:physiopathology; D005260:Female; D006791:Hostility; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D010101:Oxygen Consumption / Q000502:physiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D013315:Stress, Psychological / Q000175:diagnosis / Q000453:epidemiology* / Q000503:physiopathology; D013318:Stroke Volume / Q000502:physiology
keywords: Cardiac rehabilitation; Depression; Mortality; Psychological stress