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(Circulation. 2001;104:2018.)
© 2001 American Heart Association, Inc.

Clinical Investigation and Reports

Reducing Emotional Distress Improves Prognosis in Coronary Heart Disease

9-Year Mortality in a Clinical Trial of Rehabilitation

Johan Denollet, PhD; Dirk L. Brutsaert, MD

From the Department of Clinical Health Psychology, Tilburg University, the Netherlands (J.D.), and the Center for Cardiac Rehabilitation, University Hospital of Antwerp, Belgium (J.D., D.L.B.).

Correspondence to Johan Denollet, PhD, Clinical Health Psychology, Room P508, Tilburg University, Warandelaan, 2, PO Box 90153, 5000 LE Tilburg, the Netherlands. E-mail j.denollet{at}kub.nl

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.

Key Words: myocardial infarction • mortality • stress • depression • trials

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