CORRESPONDENCE: LETTERS TO THE EDITOR
Cardiac Rehabilitation, Exercise Training, and Psychosocial Risk Factors
Carl J. Lavie, MD, FACC* and
Richard V. Milani, MD, FACC
* Department of Cardiac Rehabilitation and Prevention, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, Louisiana 70121 (Email: clavie{at}ochsner.org).
The recent review by Rozanski et al. (1) outlined the important role of behavioral and psychosocial risk factors in the pathogenesis and expression of cardiovascular (CV) diseases, particularly coronary artery disease (CAD). Although the investigators briefly mentioned the potential for exercise training to improve prognosis in patients with depression, as well as the role of adding psychosocial intervention to standard cardiac rehabilitation programs to reduce subsequent major CAD events (1,2), they mainly emphasized the role of behavioral and psychopharmacologic interventions.
Formal phase II cardiac rehabilitation and exercise training programs, however, are known to produce marked benefits on exercise capacity, plasma lipids, obesity indices, inflammation, metabolic syndrome, autonomic function, blood viscosity and rheology, measures of ventricular repolarization dispersion, subsequent hospitalization costs, as well as major CV morbidity and mortality (3–5). In addition to producing over 50% reductions in the prevalence of depressive symptoms (6–9), we have also demonstrated that formal cardiac rehabilitation programs, with general but without specific psychosocial intervention, also produced nearly 50% reductions in both prevalence of hostility symptoms (10,11) and high levels of anxiety symptoms (12) as well as markedly reducing somatization and all aspects of psychological distress. In our studies, patients with adverse behavioral factors generally had other adverse CAD risk profiles, including low exercise capacities, hypertriglyceridemia, low high-density lipoprotein cholesterol levels, elevated plasma glucose, and reduced quality of life scores compared with patients without these adverse psychological factors, and all these parameters markedly improved following formal cardiac rehabilitation and exercise training programs.
We agree with Rozanski et al. (1) that further emphasis on the emerging importance of psychosocial and behavioral risk factors is needed and that a sophisticated healthcare delivery system may be needed to optimize intervention in these disorders. However, we also believe that greater physician input is needed to increase referrals, attendance, and completion of the readily available and proven, yet greatly underutilized, cardiac rehabilitation and exercise training programs to enhance psychosocial and behavioral adaptation and the secondary prevention of CAD.
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1. Rozanski A, Blumenthal JA, Davidson KW, et al. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice J Am Coll Cardiol 2005;45:637-651.[Abstract/Free Full Text]2. Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery diseasea meta-analysis. Arch Intern Med 1996;156:745-752.[Abstract/Free Full Text] 3. Lavie CJ, Milani RV, Littman AB. Benefits of cardiac rehabilitation and exercise training in secondary coronary prevention in the elderly J Am Coll Cardiol 1993;22:678-683.[Abstract] 4. Milani RV, Lavie CJ, Mehra MR. Reduction in C-reactive protein through cardiac rehabilitation and exercise training J Am Coll Cardiol 2004;43:1056-1061.[Abstract/Free Full Text] 5. Milani RV, Lavie CJ. Prevalence and profile of metabolic syndrome in patients following acute coronary events and effects of therapeutic lifestyle change with cardiac rehabilitation Am J Cardiol 2003;92:50-54.[Web of Science][Medline] 6. Milani RV, Lavie CJ, Cassidy MM. Effects of cardiac rehabilitation and exercise training programs on depression in patients following major coronary events Am Heart J 1996;132:726-732.[CrossRef][Web of Science][Medline] 7. Milani RV, Lavie CJ. Behavioral differences and effects of cardiac rehabilitation and exercise training in diabetic patients following major cardiac events Am J Med 1996;100:517-523.[CrossRef][Web of Science][Medline] 8. Milani RV, Lavie CJ. Prevalence and effects of cardiac rehabilitation on depression in the elderly with coronary heart disease Am J Cardiol 1998;81:1233-1236.[CrossRef][Web of Science][Medline] 9. Lavie CJ, Milani RV, Cassidy MM, et al. Effects of cardiac rehabilitation and exercise training programs in women with depression Am J Cardiol 1999;83:1480-1483.[CrossRef][Web of Science][Medline] 10. Lavie CJ, Milani RV. Effects of cardiac rehabilitation and exercise training programs on coronary patients with high levels of hostility Mayo Clin Proc 1999;74:959-966.[Abstract] 11. Lavie CJ, Milani RV. Prevalence of hostility in young coronary patients and effects of cardiac rehabilitation and exercise training Mayo Clin Proc 2005;80:335-342.[Abstract/Free Full Text] 12. Lavie CJ, Milani RV. High prevalence of anxiety in coronary patients with improvements following cardiac rehabilitation and exercise training Am J Cardiol 2004;93:336-339.[CrossRef][Web of Science][Medline]
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