Significance of comorbid psychological stress and depression on outcomes after cardiac rehabilitation

Kachur, Sergey, Menezes, Arthur R., De Schutter, Alban, Milani, Richard V. and Lavie, Carl J. (2016) Significance of comorbid psychological stress and depression on outcomes after cardiac rehabilitation. American Journal of Medicine, 129 12: 1316-1321. doi:10.1016/j.amjmed.2016.07.006

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Author Kachur, Sergey
Menezes, Arthur R.
De Schutter, Alban
Milani, Richard V.
Lavie, Carl J.
Title Significance of comorbid psychological stress and depression on outcomes after cardiac rehabilitation
Journal name American Journal of Medicine   Check publisher's open access policy
ISSN 1555-7162
Publication date 2016-12-01
Year available 2016
Sub-type Article (original research)
DOI 10.1016/j.amjmed.2016.07.006
Open Access Status File (Author Post-print)
Volume 129
Issue 12
Start page 1316
End page 1321
Total pages 6
Place of publication New York, NY United States
Publisher Elsevier
Language eng
Formatted abstract

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.

Patients and 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.


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).


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.
Keyword Cardiac rehabilitation
Psychological stress
Q-Index Code C1
Q-Index Status Provisional Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
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