title: Can the Type A Behavior Pattern be Altered after Myocardial Infarction? A Second Year Report from the Recurrent Coronary Prevention Project The impact of cognitive behavioral group training on event-free survival in patients with myocardial infarction: the ENRICHD experience. Brief Group Therapy in Myocardial Infarction Rehabilitation: Three‐ to Four‐Year Follow‐Up of a Controlled Trial* Treatment of depression after coronary artery bypass surgery: a randomized controlled trial. Depression and Late Mortality After Myocardial Infarction in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Study Physical training and relaxation therapy in cardiac rehabilitation assessed through a composite criterion for training outcome. An integrated secondary prevention group programme reduces depression in cardiac patients Stress Reduction in the Secondary Prevention of Cardiovascular Disease: Randomized, Controlled Trial of Transcendental Meditation and Health Education in Blacks The Enhancing Recovery in Coronary Heart Disease Trial (ENRICHD): strategies and techniques for enhancing retention of patients with acute myocardial infarction and depression or social isolation. Enhancing Recovery in Coronary Heart Disease (ENRICHD) Study Intervention: Rationale and Design Enhancing recovery in coronary heart disease patients (ENRICHD): study design and methods. The ENRICHD investigators. A randomised, feasibility trial of a tele-health intervention for Acute Coronary Syndrome patients with depression ('MoodCare'): Study protocol Effects of a home-based intervention program on anxiety and depression 6 months after coronary artery bypass grafting: a randomized controlled trial. Women’s hearts need special treatment Psychological rehabilitation after myocardial infarction: multicentre randomised controlled trial The outcomes of interpersonal counselling on depressive symptoms and distress after myocardial infarction Guideline-based early rehabilitation after myocardial infarction. A pragmatic randomised controlled trial. Social support and prognosis in patients at increased psychosocial risk recovering from myocardial infarction. Effects of Treating Exhaustion in Angioplasty Patients on New Coronary Events: Results of the Randomized Exhaustion Intervention Trial (EXIT) Effects of a stress management program on vital exhaustion and depression in women with coronary heart disease: a randomized controlled intervention study. A randomized control trial of cardiac rehabilitation. The effect of a psychosocial intervention and quality of life after acute myocardial infarction: the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial. Cognitive-behavioural stress management does not improve biological cardiovascular risk indicators in women with ischaemic heart disease: a randomized-controlled trial. Exercise, depression, and mortality after myocardial infarction in the ENRICHD trial. Long-term efficacy of a tele-health intervention for acute coronary syndrome patients with depression: 12-month results of the MoodCare randomized controlled trial Psychological effects of a short behavior modification program in patients with acute myocardial infarction or coronary artery bypass grafting. A randomized controlled trial. Effects of type A behavioral counseling and severity of prior acute myocardial infarction on survival. Cardiac events after myocardial infarction: possible effect of relaxation therapy. Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project. Randomised controlled trial of group cognitive behaviour therapy versus brief intervention for depression in cardiac patients The group counseling v exercise therapy study. A controlled intervention with subjects following myocardial infarction. Psychological and Quality-of-Life Outcomes from a Comprehensive Stress Reduction and Lifestyle Program in Patients with Coronary Artery Disease: Results of a Randomized Trial Brief strategic therapy in first myocardial infarction patients with increased levels of stress: a randomized clinical trial Enhanced depression care for patients with acute coronary syndrome and persistent depressive symptoms: coronary psychosocial evaluation studies randomized controlled trial. Effects of a health education programme with telephone follow-up during cardiac rehabilitation. Daily Stress and Social Support among Women with CAD: Results from a 1-year Randomized Controlled Stress Management Intervention Study Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Change in coronary‐prone behaviors in the recurrent coronary prevention project. Women's hearts--stress management for women with ischemic heart disease: explanatory analyses of a randomized controlled trial. One-year results of the randomized, controlled, short-term psychotherapy in acute myocardial infarction (STEP-IN-AMI) trial. Psychic effects of physical training and relaxation therapy after myocardial infarction. The Effect of a Telephone Counseling Intervention on Self-Rated Health of Cardiac Patients Smoking Behavior Postmyocardial Infarction Among ENRICHD Trial Participants: Cognitive Behavior Therapy Intervention for Depression and Low Perceived Social Support Compared With Care as Usual Effect of intervention for psychological distress on rehospitalization rates in cardiac rehabilitation patients. Effect of relaxation therapy on cardiac events after myocardial infarction: a 5-year follow-up study. Rationale and trial design of a randomized, controlled study on short-term psychotherapy after acute myocardial infarction: the STEP-IN-AMI trial (Short Term Psychotherapy in Acute Myocardial Infarction) Treating persistent depressive symptoms in post-ACS patients: the project COPES phase-I randomized controlled trial. The effect of enhanced depression care on adherence to risk-reducing behaviors after acute coronary syndromes: findings from the COPES trial. Psychosocial Treatment Within Sex by Ethnicity Subgroups in the Enhancing Recovery in Coronary Heart Disease Clinical Trial Short-TErm Psychotherapy IN Acute Myocardial Infarction (STEP-IN-AMI) Trial: Final Results. Treating Anxiety in Patients with Coronary Heart Disease: A Randomized Controlled Trial Enhancing Cardiac Rehabilitation With Stress Management Training: A Randomized, Clinical Efficacy Trial
abstract: & NA ; The feasibility of altering a Type A style of life was investigated in 1012 nonsmoking predominantly male postinfa rct ion volunteers in the San Francisco Bay area . A total of 862 were r and omly allocated into an experimental section receiving a combination of Type A and cardiac counseling , or a control section receiving cardiac counseling alone . The remaining 150 formed a nonr and om but statistically equivalent comparison section . Assessment s of change in Type A behavior were made by the participant , his or her spouse , a work colleague , and an independent rater of a videotaped structured interview . Psychometric analyses indicated that these instruments were valid and reliable measures of Type A behavior . After 24 months , participants receiving Type A/cardiac counseling exhibited a significantly greater reduction in Type A behavior than the other two sections , and had a lower cardiovascular recurrence rate than the comparison section only . No differences among the three sections were observed in total cholesterol or resting blood pressure . The results suggest that Type A behavior can be altered by group counseling in postinfa rct ion volunteers and that such alteration is superior to no group counseling at all in the secondary prevention of coronary heart disease OBJECTIVE Although the Enhancing Recovery in Coronary Heart Disease ( ENRICHD ) treatment was design ed to include individual therapy and cognitive behavioral group training for patients with depression and /or low perceived social support , only 31 % of treated participants received group training .  Secondary analyses classified intervention participants into two subgroups , ( 1 ) individual therapy only or ( 2 ) group training ( i.e. , coping skills training ) plus individual therapy , to determine whether medical outcomes differed in participants who received the combination of group training and individual therapy compared to participants who received individual therapy only or usual care . METHODS Secondary analyses of 1243 usual care , 781 individual therapy only , and 356 group plus individual therapy myocardial infa rct ion ( MI ) patients were performed . Depression was diagnosed using modified Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition ( DSM-IV ) criteria ; low perceived social support was determined by the ENRICHD Social Support Instrument . Psychosocial treatment followed MI , and for participants with severe or unremitting depression , was supplemented with a selective serotonin reuptake inhibitor . Cox proportional hazards regression was used to estimate intervention effects on time to first occurrence of the composite end point of death plus nonfatal MI . To control for confounding of group participation with survival ( because individual sessions preceded group ) , we used risk set sampling to match minimal survival time of those receiving or not receiving group training . RESULTS Analyses correcting for differential survival among comparison groups showed that group plus individual therapy was associated with a 33 % reduction ( hazard ratio=0.67 ; 95 % confidence interval , 0.49 - 0.92 , P=.01 ) in medical outcome compared to usual care . No significant effect on event-free survival was associated with individual therapy alone . The group training benefit was reduced to 23 % ( hazard ratio=0.77 ; 95 % confidence interval : 0.56 - 1.07 , P=.11 ) in the multivariate-adjusted model . CONCLUSIONS Findings suggest that adding group training to individual therapy may be associated with reduction in the composite end point . A r and omized controlled trial is warranted to definitively resolve this issue & NA ; A trial of brief group therapy as part of a rehabilitation program for postmyocardial infa rct ion ( MI ) patients was carried out . Forty‐four patients surviving their first MI were r and omly allocated to either group therapy or control group status and were followed over 4 years . An additional group of 17 patients were referred for post‐MI group therapy sessions after the termination of the controlled experiment and were followed for 3 years . Patients who received group therapy had significantly less follow‐up coronary morbidity and mortality , and returned to work at significant higher percentages than control patients . Although neither group therapy nor control group patients meaningfully altered conventional coronary risk factors , group therapy patients ( in the controlled trial ) successfully altered selected coronary‐prone behaviors . Educational information regarding the physiological and psychological aspects of coronary heart disease , presented in the group therapy sessions , was forgotten over follow‐up . It is concluded that the supportive aspects of the group therapy experience played the most important role in determining the rehabilitation advantages seen for treatment patients CONTEXT There has been little research on the treatment of depression after coronary artery bypass surgery . OBJECTIVE To test the efficacy of 2 nonpharmacological interventions for depression after  coronary artery bypass surgery  compared with usual care . DESIGN A 12-week , r and omized , single-blind clinical trial with outcome evaluations at 3 , 6 , and 9 months . SETTING Outpatient research clinic at Washington University School of Medicine , St Louis , Missouri . PATIENTS One hundred twenty-three patients who met the DSM-IV criteria for major or minor depression within 1 year after surgery . INTERVENTION Twelve weeks of cognitive behavior therapy or supportive stress management .  Approximately half of the participants were taking non study antidepressant medications .  MAIN OUTCOME MEASURE Remission of depression , defined as a score of less than 7 on the 17-item Hamilton Rating Scale for Depression . RESULTS Remission of depression occurred by 3 months in a higher proportion of patients in the cognitive behavior therapy ( 71 % ) and supportive stress-management ( 57 % ) arms than in the usual care group ( 33 % ) ( chi(2)(2 ) = 12.22 , P = .002 ) . Covariate-adjusted Hamilton scores were lower in the cognitive behavior therapy ( mean [ st and ard error ] , 5.5 [ 1.0 ] ) and the supportive stress-management ( 7.8 [ 1.0 ] ) arms than in the usual care arm ( 10.7 [ 1.0 ] ) at 3 months . The differences narrowed at 6 months , but the remission rates differed again at 9 months ( 73 % , 57 % , and 35 % , respectively ; chi(2)(2 ) = 12.02 , P = .003 ) . Cognitive behavior therapy was superior to usual care at most points on secondary measures of depression , anxiety , hopelessness , stress , and quality of life . Supportive stress management was superior to usual care only on some of the measures . CONCLUSIONS Both cognitive behavior therapy and supportive stress management are efficacious for treating depression after coronary artery bypass surgery , relative to usual care . Cognitive behavior therapy had greater and more durable effects than supportive stress management on depression and several secondary psychological outcomes . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00042198 Objective : The Enhancing Recovery in Coronary Heart Disease study was a multicenter clinical trial in which patients with depression and /or low perceived social support after an acute myocardial infa rct ion were r and omly assigned to an intervention consisting of cognitive behavior therapy and , in some cases , sertraline , or to usual care . There was no difference in survival between the groups . A possible reason why the intervention failed to affect survival is that too many patients with mild , transient depression were enrolled . Another is that some patients died too soon to complete the intervention . This analysis evaluates whether there was a difference in late ( ie , ≥6 months after the myocardial infa rct ion ) mortality among initially depressed patients who had a Beck Depression Inventory score ≥10 and a past history of major depression , and who completed the 6-month post-treatment assessment . It also examines the relationship between change in depression and late mortality . Methods : Out of the 1,165 ( 47 % ) of the Enhancing Recovery in Coronary Heart Disease study participants who met our criteria , 57 died  in the first 6 months , and 858 ( 409 usual care , 449 intervention ) completed the 6-month assessment . Cox regression was used to analyze survival . Results : The intervention did not affect late mortality . However , intervention patients whose depression did not improve were at higher risk for late mortality than were patients who responded to treatment . Conclusions : Patients whose depression is refractory to cognitive behavior therapy and sertraline , two st and ard treatments for depression , are at high risk for late mortality after myocardial infa rct ion One hundred fifty-six myocardial infa rct ion patients were r and omly assigned to either exercise plus relaxation and breathing therapy ( treatment A , n = 76 ) or to exercise training only ( treatment B , n = 80 ) . Effects on exercise testing showed a more pronounced training bradycardia and a remarkable improvement in ST abnormalities in treatment A ( p less than 0.005 ) . A model was developed to integrate the various exercise parameters into a single measure for training benefit . Approximately half the patients showed a training success , with a more positive and less negative outcome in treatment A ( p = 0.09 ) . The odds for failure were 0.25 for treatment A and 0.51 for treatment B ( odds ratio : 2.04 ; 95 % confidence interval , 0.94 to 4.6 ) . Thus the risk of failure was reduced by half when relaxation was added to exercise training . These results indicate that exercise training is not successful in all MI patients and that relaxation therapy enhances training benefit Objective Depression is common following an acute cardiac event and can occur at a time when behaviour change is strongly recommended to reduce the risk of further cardiovascular events . The ‘ Beating Heart Problems ’ programme was design ed to support cardiac patients in behaviour change and mood management . Methods The programme was based on cognitive behaviour therapy and motivational interviewing . A r and omized controlled trial ( RCT ) comparing the 8-week group programme with usual care was undertaken between 2007 and 2010 . All patients attended a hospital-based clinic for assessment of physiological risk factors at baseline ( 6 weeks after their acute event ) , and at 4- and 12-month follow up . Psychological and behavioural indicators were assessed by self-report question naires . Of the 275 patients enrolled into the RCT , 42 ( 15 % ) had Beck Depression Inventory-II scores > 13 at baseline . Treatment and control group comparisons were undertaken for this subgroup , using growth curve modelling and testing for group differences over time in psychological , physiological , health behaviour , and self-efficacy measures . Results Significantly greater improvements ( p < 0.01 ) in depression symptoms and self-rated health were reported for the intervention group , as well as significantly larger gains in confidence in managing depression ( p < 0.05 ) and anger ( p < 0.01 ) . Trends ( 0.05 < p < 0.10 ) for larger treatment group improvements were also seen for anxiety symptoms and confidence in managing anxiety . Conclusion A group secondary -prevention programme that integrates behavioural and mood management strategies leads to decreased depression , increased confidence , and improved health perceptions in depressed cardiac patients Background —Blacks have disproportionately high rates of cardiovascular disease . Psychosocial stress may contribute to this disparity . Previous trials on stress reduction with the Transcendental Meditation ( TM ) program have reported improvements in cardiovascular disease risk factors , surrogate end points , and mortality in blacks and other population s. Methods and Results —This was a r and omized , controlled trial of 201 black men and women with coronary heart disease who were r and omized to the TM program or health education .  The primary end point was the composite of all-cause mortality , myocardial infa rct ion , or stroke . Secondary end points included the composite of cardiovascular mortality , revascularizations , and cardiovascular hospitalizations ; blood pressure ; psychosocial stress factors ; and lifestyle behaviors . During an average follow-up of 5.4 years , there was a 48 % risk reduction in the primary end point in the TM group ( hazard ratio , 0.52 ; 95 % confidence interval , 0.29–0.92 ; P=0.025 ) . The TM group also showed a 24 % risk reduction in the secondary end point ( hazard ratio , 0.76 ; 95 % confidence interval , 0.51–0.1.13 ; P=0.17 ) . There were reductions of 4.9 mmHg in systolic blood pressure ( 95 % confidence interval −8.3 to –1.5 mmHg ; P=0.01 ) and anger expression ( P<0.05 for all scales ) . Adherence was associated with survival . Conclusions —A selected mind – body intervention , the TM program , significantly reduced risk for mortality , myocardial infa rct ion , and stroke in coronary heart disease patients . These changes were associated with lower blood pressure and psychosocial stress factors . Therefore , this practice may be clinical ly useful in the secondary prevention of cardiovascular disease . Clinical Trial Registration —URL : www . clinical trials.gov Unique identifier : NCT01299935 The report aims to review the literature and describe the methods used for retention of patients in a clinical study . The Enhanced Recovery in Coronary Heart Disease ( ENRICHD ) trial was a multicenter , r and omized clinical trial design ed to evaluate the effects of a psychosocial intervention on cardiovascular morbidity and mortality . A total of 2481 patients met the criteria for depression , low social support , or both after a myocardial infa rct ion and needed to be followed . Follow-up evaluation consisted of telephone interviews 3 , 9 , 12 , 24 , 36 , and 48 months after enrollment and clinic visits scheduled at 6 , 18 , 30 , 42 , and 54 months . Creative strategies used to achieve optimum retention of this complex patient population over a long follow-up period are presented . Strategies to enhance adherence throughout the course of the trial required adequate tracking of patients to ensure minimum dropout , follow-up evaluation optimized through multiple methods of contact to guarantee completeness of data collection ; and development of procedures to address the needs of patients at risk for dropout . Patients in the group that completed the study participated for a mean of 28.3 months , and those lost to follow-up evaluation participated for a mean of 19 months . Retention was not substantially different by gender or minority status . The results of this project can assist investigators in planning studies that require patient follow-up evaluation , and can provide clinicians with specific strategies for maximizing retention-to-treatment recommendations . As a result of the retention strategies described in this report , 93.02 % of the patients completed their study participation or died . This is a very high retention rate given the complexity of the study sample , protocol , and required duration of follow-up evaluation Objective Depression and low social support are risk factors for medical morbidity and mortality after acute MI . The ENRICHD study is a multicenter , r and omized , controlled clinical trial of a cognitive-behavioral treatment for depression and low social support in post-MI patients . A total of 2481 patients were recruited ( 26 % with low social support , 39 % with depression , and 34 % with low social support and depression ) . Our objective is to describe the rationale , design , and delivery of the ENRICHD intervention . Methods Key features of the intervention include the integration of cognitive-behavioral and social learning approaches to the treatment of depression and a diverse set of problems that can contribute to low social support ; rapid initiation of treatment after MI ; a combination of individual and group modalities ; adjunctive pharmacotherapy for severe or intractable depression ; training , certification , and supervision of therapists ; and quality assurance procedures . Results The trial ’s psychosocial and medical outcomes will be presented in future reports . Conclusions The ENRICHD protocol targets two complex psychosocial risk factors with a multifaceted intervention , which is delivered in an individualized manner to accommo date a demographically , medically , and psychiatrically diverse patient population . Additional research will be needed to identify optimal matches between patient characteristics and specific components of the intervention Psychosocial factors , particularly depression and lack of social support , are important predictors of morbidity and mortality in patients with coronary heart disease . This article describes the design and methods of the Enhancing Recovery in Coronary Heart Disease Patients ( ENRICHD ) study , a multicenter , r and omized clinical trial involving 3000 patients enrolled after acute myocardial infa rct ion . ENRICHD aims to investigate the effects of a psychosocial intervention that targets depression and /or low social support on survival and reinfa rct ion among adult men and women who are at high risk for recurrent cardiac events because of psychosocial factors ( depressive or social isolation ) . Design features include the use of an individually tailored yet st and ardized intervention , rigorous clinical trial methods , and enrollment of a large number of women and minorities Background Coronary heart disease ( CHD ) and depression are leading causes of disease burden globally and the two often co-exist . Depression is common after Myocardial Infa rct ion ( MI ) and it has been estimated that 15 - 35 % of patients experience depressive symptoms . Co-morbid depression can impair health related quality of life ( HRQOL ) , decrease medication adherence and appropriate utilisation of health services , lead to increased morbidity and suicide risk , and is associated with poorer CHD risk factor profiles and reduced survival . We aim to determine the feasibility of conducting a r and omised , multi-centre trial design ed to compare a tele-health program ( MoodCare ) for depression and CHD secondary prevention , with Usual Care ( UC ) . Methods Over 1600 patients admitted after index admission for Acute Coronary Syndrome ( ACS ) are being screened for depression at six metropolitan hospitals in the Australian states of Victoria and Queensl and . Consenting participants are then contacted at two weeks post-discharge for baseline assessment . One hundred eligible participants are to be r and omised to an intervention or a usual medical care control group ( 50 per group ) . The intervention consists of up to 10 × 30 - 40 minute structured telephone sessions , delivered by registered psychologists , commencing within two weeks of baseline screening . The intervention focuses on depression management , lifestyle factors ( physical activity , healthy eating , smoking cessation , alcohol intake ) , medication adherence and managing co-morbidities . Data collection occurs at baseline ( Time 1 ) , 6 months ( post-intervention ) ( Time 2 ) , 12 months ( Time 3 ) and 24 months follow-up for longer term effects ( Time 4 ) . We are comparing depression ( Cardiac Depression Scale [ CDS ] ) and HRQOL ( Short Form-12 [ SF-12 ] ) scores between treatment and UC groups , assessing the feasibility of the program through patient acceptability and exploring long term maintenance effects . A cost-effectiveness analysis of the costs and outcomes for patients in the intervention and control groups is being conducted from the perspective of health care costs to the government . Discussion This manuscript presents the protocol for a r and omised , multi-centre trial to evaluate the feasibility of a tele-based depression management and CHD secondary prevention program for ACS patients . The results of this trial will provide valuable new information about potential psychological and wellbeing benefits , cost-effectiveness and acceptability of an innovative tele-based depression management and secondary prevention program for CHD patients experiencing depression . Trial Registration NumberAustralia and New Zeal and Clinical Trials Register ( ANZCTR ) : OBJECTIVE The objective of this study was to evaluate the effects of a home-based intervention program ( HBIP ) on anxiety and depression 6 months after coronary artery bypass grafting ( CABG ) .  METHODS In a prospect i ve r and omized controlled trial , 203 elective CABG patients were included . An HBIP structured for respondents in the intervention group was performed 2 and 4 weeks after surgery . Anxiety and depression symptoms were measured by the Hospital Anxiety and Depression Scale ( HADS ) in both patient groups before surgery , 6 weeks after surgery , and 6 months after surgery . RESULTS A total of 185 patients completed the study : 93 patients in the intervention group and 92 patients in the control group . On 6-week and 6-month follow-ups , significant improvements in anxiety and depression symptoms were found in both groups . These improvements did not differ significantly between the groups . However , in a predefined subgroup of patients with anxiety and /or depression symptoms at baseline ( n=65 ) , improvement was significantly larger in the intervention group ( n=29 ) than in the control group ( n=36 ) after 6 months ( P<.05 ) . CONCLUSIONS Patients experiencing high levels of psychological distress before CABG surgery benefited from a structured informational and psychological HBIP . Implementation of psychological screens of patients scheduled for CABG might serve to identify patients experiencing anxiety and /or depression . These patients could then be targeted to receive individualized HBIP Coronary heart disease ( CHD ) is the leading cause of death for both men and women in the Western world . Some studies show that the observed decline in cardiovascular mortality is not as pronounced among women as among men . There is a growing awareness that most earlier studies both on primary and secondary risk factors , diagnosis , prognosis , and rehabilitation have focused mainly on men . Thus , there is a need to develop knowledge about women with CHD and to address gender issues in treatment and rehabilitation strategies . Negative affect and emotions increase risk and may interfere with effective cardiac rehabilitation . Therefore , methods for coping with emotional stress need to be included in treatment regimens after a coronary event . The feasibility of a stress management program for women with CHD was assessed in a pilot study . The program consisted of twenty 2-hr group sessions during 1 year , with 5 to 9 participants per group . The pilot study showed that this treatment program had a low dropout rate and result ed in improvement in quality of life and reduction in stress and symptoms . Further work to optimize psychosocial interventions for women with CHD is needed Abstract Objective : To evaluate rehabilitation  after myocardial infa rct ion . Design : R and omised controlled trial of rehabilitation in unselected myocardial infa rct ion patients in six centres , baseline data being collected on admission and by structured interview ( of patients and spouses ) shortly after discharge and outcome being assessed by structured interview at six months and clinical examination at 12 months . Setting : Six district general hospitals . Subjects : All 2328 eligible patients admitted over two years with confirmed myocardial infa rct ion and discharged home within 28 days . Interventions : Rehabilitation programmes comprising psychological therapy , counselling , relaxation training , and stress management training over seven weekly group outpatient sessions for patients and spouses . Main outcome measures : Anxiety , depression , quality of life , morbidity , use of medication , and mortality . Results : At six months there were no significant differences between rehabilitation patients and controls in reported anxiety ( prevalence 33 % ) or depression ( 19 % ) . Rehabilitation patients reported a lower frequency of angina ( median three versus four episodes a week ) , medication , and physical activity . At 12 months there were no differences in clinical complications , clinical sequelae , or mortality . Conclusions : Rehabilitation programmes based on psychological therapy , counselling , relaxation training , and stress management seem to offer little objective benefit to patients who have experienced myocardial infa rct ion compared with previous reports of smaller trials . Key messages In this series there were no important differences by age , sex , hospital , or baseline anxiety or depression At six months the prevalence rates of clinical anxiety and depression remained high ( 33 % and 19 % respectively ) Patients and spouses rated programmes highly , which suggests a “ quality of care ” role for Aims : Depression is not treated adequately after myocardial infa rct ion ( MI ) . This study evaluates the interpersonal counselling ( IPC ) implemented by a registered nurse on outcomes for depressive symptoms and distress in MI patients . Methods : We studied MI patients ( n = 103 ) r and omized into intervention group ( n = 51 ) and control group ( n = 52 ) in hospital and at 6 and 18 months after discharge using vali date d question naires , Beck 's Depression Inventory ( BDI ) and the Symptom Checklist-25 ( SCL-25 ) . Results : During the 18-month follow-up , depressive symptoms decreased statistically significantly ( P = 0.009 ) in the intervention group compared with the control group . In the IPC intervention group , depressive symptoms decreased from 37.3 % to 20.4 % at 6 months ( P = 0.014 ) , and to 16.7 % at 18 months ( P = 0.001 ) , while distress decreased from 37.3 % to 26.5 % ( P = 0.132 ) during the 6-month follow-up , and to 20.8 % ( P = 0.015 ) . In the control group with normal care , the number of patients with depressive symptoms and distress varied slightly at the three measurements , from 30.2 to 39.6 % . Conclusions : The number of patients with depressive symptoms and distress decreased in the intervention group and remained high in the control group . The progress of severity level of depressive symptoms was toward milder symptoms in the intervention group during the 18-month follow-up . This brief intervention that can rapidly be adopted may result in enduring benefits of clinical value OBJECTIVES To determine the effectiveness of individualised educational behavioural treatment delivered by cardiac nurses in hospital compared to usual care for patients following acute myocardial infa rct ion . METHODS One hundred and fourteen consecutive patients were r and omised to receive the intervention or usual care . Outcome assessment was by self-report question naire ( the Hospital Anxiety and Depression Scale and Dartmouth COOP Health Status ) , interview at 1 month , and self-report at 3 and 12 months . The primary outcome was improvement in the Dartmouth COOP total score from baseline to 3 months . RESULTS Four patients needed to be treated to give an additional patient with improvement in health status at 3 months ( number needed to treat [ NNT ] 4 , 95 % confidence intervals [ CIs ] 3 to 12 ) . The intervention group were more confident about returning to activities 1 month after discharge from hospital . Treated patients had fewer further treatment needs . CONCLUSIONS An individualised educational behavioural treatment delivered by cardiac nurses in hospital may have substantial benefits . A large-scale pragmatic RCT is needed OBJECTIVE To compare the impact of network support and different types of perceived functional support on all-cause mortality or nonfatal reinfa rct ion for patients with a recent acute myocardial infa rct ion ( AMI ) . DESIGN Participants were recruited from the Enhancing Recovery in Coronary Heart Disease ( ENRICHD ) trial ; 2,481 AMI patients with depression or low social support were r and omized to a cognitive-behavioral intervention or to a usual care control group . Data collection for certain measures of social support was limited : 2,466 participants completed the ENRICHD Social Support Inventory ; 2,457 completed the Perceived Social Support Scale ; 1,296 completed the Social Network Question naire ; and 707 completed the Interpersonal Support and Evaluation List , Tangible Support subscale . Patients also completed the Beck Depression Inventory and were followed for up to 4.5 years . MAIN OUTCOME MEASURE Time to death or nonfatal reinfa rct ion . RESULTS Over the follow-up period , 599 patients ( 24 % ) died or had a nonfatal AMI . Survival models controlling age , sex , race , socioeconomic status , smoking , antidepressant use , and a composite measure of increased risk revealed that higher levels of perceived social support were associated with improved outcome for patients without elevated depression but not for patients with high levels of depression . Neither perceived tangible support nor network support were associated with more frequent adverse events . CONCLUSION AMI patients should be assessed for multiple dimensions of perceived functional support and depression to identify those at increased psychosocial risk who may benefit from treatment Background : Extreme fatigue is a common complaint in percutaneous coronary intervention ( PCI ) patients , and is associated with an increased risk for new cardiac events . The objective of the Exhaustion Intervention Trial ( EXIT ) was to determine whether a behavioral intervention on exhaustion reduces the risk of a new coronary event after PCI . Methods and Results : Seven hundred ten consecutive patients , ages 35 to 68 years , who felt exhausted after PCI were r and omized into an  intervention group  and a  usual-care group . The intervention was based on group therapy focusing on stressors leading to exhaustion , and on support for recovery by promoting rest and making rest more efficient . One month after PCI , 50 % of the patients felt exhausted . The intervention reduced the odds of remaining exhausted at 18 months by 56 % in those without a previous history of coronary artery disease ( CAD ) ( OR = 0.44 ; 95 % CI 0.29–0.66 ) , but had no effect on exhaustion in those with a history of CAD ( OR = 0.93 ; 95 % CI 0.56–1.55 ; p = .78 ) . The intervention did not reduce the risk of a new coronary event within 2 years ( RR = 1.14 ; 95%CI 0.82–1.57 ) . Post-hoc analyses suggest that the effect of the intervention was limited by a positive history of CAD , the presence of a chronic , painful condition ( especially rheumatism ) , and by opposite effects on early and late cardiac events . Conclusion : A  behavioral intervention in PCI patients has a beneficial effect on feelings of exhaustion . It could not be demonstrated that the intervention reduces the risk of a new coronary event within 2 years . PCI = percutaneous coronary intervention ; CAD = coronary artery disease ; MQ = Maastricht Question naire ; MIVE = Maastricht Interview Vital Exhaustion ; EXIT = Exhaustion Intervention Trial ; CABG = coronary artery bypass graft ; MI = myocardial infa rct ion OBJECTIVES Psychosocial factors , including depression and vital exhaustion ( VE ) are associated with adverse outcome in coronary heart disease ( CHD ) . Women with CHD are poor responders to psychosocial treatment and knowledge regarding which treatment modality works in them is limited . This r and omized controlled clinical study evaluated the effect of a 1-year stress management program , aim ed at reducing symptoms of depression and VE in CHD women . DESIGN Patients were 247 women , < or = 75 years , recruited consecutively after a cardiac event and r and omly assigned to either stress management ( 20 2-h sessions ) and medical care by a cardiologist , or to obtaining usual health care as controls . Measurements at ; baseline ( 6 - 8 weeks after r and omization ) , 10 weeks ( after 10 intervention sessions ) , 1 year ( end of intervention ) and 1 - 2 years follow-up . RESULTS For VE , intention to treat analysis showed effects for time ( P < 0.001 ) and time x treatment interaction ( P = 0.005 ) , reflecting that both groups improved over time , and that the decrease of VE was more pronounced in the intervention group . However , the level of VE was higher in the intervention group than amongst controls at baseline , 22.7 vs. 19.4 ( P = 0.036 ) but it did not differ later . The change in depressive symptoms did not differ between the groups . CONCLUSIONS CHD women attending our program experienced a more pronounced decrease in VE than controls . However , as they had higher baseline levels , due to regression towards the mean we can not attribute the decrease in VE to the intervention . Whether the program has long-term beneficial effects needs to be evaluated A r and omized trial using controls tested whether psycho-social rehabilitation of acute myocardial infa rct ion ( MI ) patients would improve significantly their return to work rate and assessed the importance of various psychological , social , occupational , socio-demographic , and medical factors in facilitating or impeding rapid return to work .  Eighty-nine patients were assigned r and omly to participate in an experimental cardiac rehabilitation program ( rehab care ) , and 91 patients were controls who received conventional hospital rehabilitation ( usual care ) .  By the first follow-up interview at three months , patients assigned to experimental treatment were significantly less distressed psychologically and less dependent on family support than controls ( P = 0.04 and P = 0.05 , respectively ) . By the final follow-up interview at 13 months , there was a marginally significant difference in favor of the experimental group in the frequency of reported deterrents to work resumption ( P = 0.07 ) . However , the intervention did not result in a statistically significant difference in the return to work rate ( P greater than 0.10 ) . In each group , 88 % were back at work by approximately the first year after infa rct ion . In addition , the two groups were similar in the amount of time patients remained out of the workforce ( median days rehab care = 75 , usual care = 81 ; P greater than 0.10 ) . A multi-stage data analysis procedure utilizing the Cox regression technique indicated that while several independent variables had significant univariate associations with the length of time patients convalesced , outcome was most influenced by the patient 's initial cardiological status and clinical course , by the patterns of family support , and by the several variables measuring the presence of obstacles to resuming work . Our findings suggest that rehabilitation programs intervening on multiple levels ( psychological , social , occupational , and physical ) may best meet the needs of chronically ill cardiac patients . Results indicate that implementing measures addressing the patient 's general psycho-social adjustment to MI may improve existing programs PURPOSE The Enhancing Recovery in Coronary Heart Disease Patients ( ENRICHD ) clinical trial was design ed to test whether intervening on depression or low perceived social support reduces mortality and reinfa rct ion in patients with acute myocardial infa rct ion ( MI ) . This report analyzes the effect of the intervention on quality of life ( QOL ) , which was an important secondary outcome . METHODS ENRICHD was a r and omized controlled clinical trial comparing a psychosocial intervention based on cognitive behavioral therapy to usual medical care in 2,481 patients from 8 clinical centers . Patients with acute MI were included if they met criteria for depression , low perceived social support , or both .  QOL was assessed at the 6-month clinic visit in the first 1,296 patients . QOL measures included the Medical Outcomes Study Short Form summary measures of physical functioning ( SF12-PCS ) and mental functioning ( SF12-MCS ) , a Life Satisfaction Scale ( LSS ) , and a measure of overall QOL based on the ladder of life ( LOL ) technique . RESULTS There were significant treatment differences on the SF12-MCS ( difference 2.2 , 95 % confidence interval [ CI ] 1.2 - 3.2 ) , the LSS ( difference 1.0 , 95 % CI 0.5 - 1.5 ) , and the LOL ( difference 0.3 , 95 % CI 0.1 - 0.6 ) , but not on the SF12-PCS ( difference 0.8 ; 95 % CI = -0.5 - 2.0 ) . Effect sizes for the intervention on QOL outcomes were modest . CONCLUSIONS Psychosocial interventions of limited duration confer modest QOL benefits in post-MI patients who are depressed or have low perceived social support . Interventions of longer duration or greater intensity may be required to produce more substantial improvements in QOL in these patients OBJECTIVES Psychosocial factors , such as stress and vital exhaustion , are associated with an increased risk of cardiovascular events , and women report more psychosocial ill-being after an acute myocardial infa rct ion than men . We have earlier shown that a cognitive-behavioural intervention in women with ischaemic heart disease ( IHD ) improved psychosocial well-being . In the present study , we tested the hypothesis that the improvement in psychosocial well-being is associated with an improvement in biochemical indicators of cardiovascular risk . DESIGN R and omized-controlled trial in northern Sweden . SETTING Outpatient care . SUBJECTS Women with IHD were r and omized to either a 1-year cognitive-behavioural stress management programme or usual care . Of the 159 women who completed the study , 77 were in the intervention group , and 82 in the control group . INTERVENTIONS A 1-year cognitive-behavioural stress management programme versus conventional care . RESULTS Group assignment was not found to be a determinant of waist circumference , high sensitive C-reactive protein ( hs-CRP ) , fibrinogen , von Willebr and factor ( vWF ) , plasminogen activator inhibitor type 1 ( PAI-1 ) activity , tissue plasminogen activator ( tPA ) activity , tPA antigen , tPA-PAI-1 complex , leptin , or HOMA2 insulin resistance index ( HOMA2-IR ) at follow up . Changes in psychosocial variables were not associated with changes in any of the biological risk indicators . CONCLUSIONS Even if our cognitive-behavioural stress management programme had effects on proximal targets , such as stress behaviour and vital exhaustion , we found no improvement in intermediate biochemical targets related to the metabolic syndrome and IHD . Our results challenge the proposition that the relationship between psychological well-being and biological cardiovascular risk indicators is a direct cause-effect phenomenon PURPOSE The large and well-characterized population of acute myocardial infa rct ion ( AMI ) patients studied in the recently completed Enhancing Recovery in Coronary Heart Disease ( ENRICHD ) multicenter clinical trial provides a unique opportunity to examine the importance of self-reported regular physical exercise in a large cohort of patients with a recent AMI who are depressed or report low levels of social support . METHODS We prospect ively examined the association between self-reported physical exercise and all-cause mortality and cardiovascular morbidity among 2078 men ( N = 1175 ; 56.5 % ) and women ( N = 903 ; 43.5 % ) with an AMI participating in the ENRICHD Trial . Six months after suffering an AMI , patients were surveyed about their exercise habits and were then followed for up to 4 yr . RESULTS During an average 2 yr of follow-up , 187 fatal events occurred . Patients reporting regular exercise had less than half the events ( 5.7 % ) of those patients reporting they did not regularly exercise ( 12.0 % ) . After adjustment for medical and demographic variables , the hazard ratio for fatal events was 0.62 ( 95 % CI = 0.44 - 0.86 , P = 0.004 ) . The rate of nonfatal AMI among the exercisers was 6.5 % compared with 10.5 % who reported no regular exercise . After adjustment for covariates , the hazard ratio for nonfatal AMI was 0.72 ( 95 % CI = 0.52 - 0.99 , P = 0.044 ) . CONCLUSIONS The present findings demonstrate the potential value of exercise in reducing mortality and nonfatal reinfa rct ion in AMI patients at increased risk for adverse events by virtue of their either being depressed or having low social support Background Depression is common after a cardiac event ; however it often remains untreated . Previously , we reported the efficacy and feasibility of a 6-month tele-health programme ( MoodCare ) , which integrates depression management into a cardiovascular disease ( CVD ) risk reduction programme for Acute Coronary Syndrome ( ACS ) patients with low mood . Here , we evaluate the long-term efficacy of the programme at 12-month follow-up . Design A two-arm , parallel , r and omized design to compare the long-term effects of ‘ MoodCare ’ ( n = 61 ) to usual care ( UC ) ( n = 60 ) at 12 months . Method 121 ACS patients recruited from six hospitals in Victoria and Brisbane , Australia were r and omized to a  telephone-delivered cognitive behavioural therapy and risk-reduction programme or usual medical care . Mixed-model repeated measurements ( MMRM ) analysis was applied with results expressed as estimated marginal mean changes in depression and health-related quality of life ( HRQOL ) outcomes by group . Results After 12 months , treatment effects were observed for those with major depressive disorder ( MDD ) for PHQ-9 depression ( MoodCare : mean score : 6.5 ; 95 % CI : 4.9–8.0 versus UC : 9.3 ; 95 % CI : 7.7–10.9 , p = 0.012 ) ) and SF-12 mental health scores ( MoodCare : 42.5 ; 95 % CI : 39.8–45.2 versus UC : 36.8 ; 95 % CI : 34.1–39.6 , p = 0.005 ) . No beneficial treatment effects were observed in those with no MDD at baseline . Conclusion After 12 months , MoodCare was superior to UC for improving mental health outcomes for those with a clinical diagnosis of major depression . Our findings support the implementation of depression-based interventions for cardiac patients with a clinical diagnosis of depression and provide evidence of longer term efficacy to one year OBJECTIVE The effects of a short intervention on behavioral risk factor modification in patients with coronary artery disease ( CAD ) on Type A behavior , vital exhaustion , and depression were studied in a r and omized controlled trial . METHODS Acute myocardial infa rct ion patients or patients who underwent coronary artery bypass grafting ( CABG ) were r and omly assigned to an 8-week multiple risk modification group program ( n = 94 ) or to a control group ( n = 90 ) that received usual care with st and ard physical exercise training . Patients were assessed before intervention , directly after intervention , and at 9-month follow-up . RESULTS The intervention was effective in reducing hostility and total Type A behavior at postintervention ( P = .01 ) and at 9-month follow-up ( P = .03 ) . The intervention had no overall impact on vital exhaustion and depression , measured by the Beck Depression Inventory ( BDI ) , whereas we unexpectedly found that the percentage of patients with major depression was reduced in the control group but not in the intervention group . CONCLUSION The results indicate that a short behavioral intervention for coronary patients can result in relatively large and persistent reductions in cognitive aspects of Type A behavior and hostility , in particular . In view of the unwanted findings on the diagnosis of depression , however , we do not unequivocally advise the intervention to the general population of AMI and CABG patients The hypothesis under investigation was that the beneficial effect of type A behavioral counseling on survival  after acute myocardial infa rct ion ( AMI ) was conditional on the functioning of the cardiovascular system , as determined by the severity of the prior AMI . Subjects were 862 nonsmoking coronary patients in the San Francisco Bay Area , r and omized in 1978 to receive , over 4.5 years , cardiac counseling or cardiac counseling plus type A behavioral counseling .  Sixteen baseline factors plus an interaction term ( severity of AMI X behavioral counseling ) were evaluated for their prognostic significance . Behavioral counseling was not a significant predictor of coronary death in the total cohort , but the interaction between counseling and severity of the prior AMI was ( p less than 0.05 ) . Thus , the total cohort was divided into 2 subgroups of mild or serious prior AMI , and independent predictors of survival were isolated within each subgroup . In the subgroup with mild prior AMI , independent predictors were anterior AMI ( p = 0.02 ) , plasma cholesterol ( p = 0.02 ) and  behavioral counseling ( p = 0.05 ) . In the subgroup with serious prior AMI , none of the factors evaluated made a significant independent contribution . These findings suggest that a reduction in  type A behavior  may exert the greatest protection against coronary death in that subgroup of patients for whom the biologic aspects of coronary artery disease are not advanced . They also demonstrate the importance of considering the level of cardiac functioning before determining predictors of survival or optimum postcoronary care Comprehensive cardiac rehabilitation aims primarily at improving quality of life , but an effect on morbidity and mortality may also be expected , especially when changes in behaviour and life-style are induced . The value of relaxation therapy and exercise training in post myocardial infa rct ion ( MI ) patients was investigated . A group of 90 post MI patients were r and omly assigned to either exercise training plus individual relaxation and breathing therapy ( treatment A ) , or exercise training only ( treatment B ) . The occurrence of cardiac events , consisting of cardiac death and of readmission to hospital for unstable angina pectoris , coronary artery bypass grafting ( CABG ) or recurrent infa rct ion , differed significantly for the two treatment groups in the 2 - 3 years after infa rct ion . Seven out of 42 patients in treatment group A ( 17 % ) experienced a cardiac event , in contrast to 17 out of 46 ( 37 % ) patients in treatment group B , ( P = 0.05 , two-tailed ) . The results suggest that a combination of a behavioural treatment such as relaxation therapy with exercise training is more favourable for the long-term outcome after myocardial infa rct ion than is exercise training alone One thous and thirteen post myocardial infa rct ion patients were observed for 4.5 years to determine whether their type A ( coronary-prone ) behavior could be altered and the effect such alteration might have on the subsequent cardiac morbidity and mortality rates of these individuals . Eight hundred sixty-two of these individuals were r and omly assigned either to a control section of 270 participants who received group cardiac counseling or an experimental section of 592 participants who received both group cardiac counseling and type A behavioral counseling . The remaining 151 patients , serving as a " comparison group , " did not receive group counseling of any kind . Using the " Intention-to-Treat " principle , we observed markedly reduced type A behavior at the end of 4.5 years in 35.1 % of participants given cardiac and type A behavior counseling compared with 9.8 % of participants given only cardiac counseling . The cumulative 4.5-year cardiac recurrence rate was 12.9 % in the 592 participants in the experimental group that received type A counseling . This recurrence rate was significantly less ( p less than 0.005 ) than either the recurrence rate ( 21.2 % ) observed in the 270 participants in the control group or the recurrence rate ( 28.2 % ) in those of the comparison group not receiving any special treatment . After the first year , a significant difference in number of cardiac deaths between the experimental and control participants was observed during the remaining 3.5 years of the study . Overall , the results of this study demonstrate for the first time , within a controlled experimental design , that altering type A behavior reduces cardiac morbidity and mortality in post infa rct ion patients Objective : To determine whether a six-session group cognitive behaviour therapy ( CBT ) programme results in a greater reduction in depression symptoms than a brief intervention alone in cardiac patients with clinical ly significant symptoms of depression . Method : Fifty-seven community dwelling cardiac patients scoring > 13 on the Beck Depression Inventory-II ( BDI-II ) received a single-session brief intervention . They were then block r and omised to either six sessions of group CBT ( n = 25 ) or no further intervention ( BI ; n = 32 ) . All were re-assessed at 2 , 6 and 12 months . Differences between treatment groups in the primary ( BDI-II ) and secondary [ rates of depression ; anxiety symptoms , as measured by the Hospital Anxiety and Depression Scale-Anxiety ( HADS-A ) ] outcomes were examined using generalised linear mixed models with a r and om intercept term for the individual . Results : Significant improvements were seen for the total group from baseline to 12 months on BDI-II and HADS-A scores . However , no differences were found between the CBT and BI conditions on change in BDI-II score , rates of major depressive episode or HADS-A score . Post hoc analysis on the total group found 12-month symptom non-remission was associated with higher baseline BDI-II score ( p = 0.03 ) , more visits to health professionals 12 months prior to baseline ( p = 0.05 ) and a greater likelihood of either drinking alcohol over recommended levels or smoking at baseline ( p = 0.01 ) . Conclusions : Group CBT of up to six sessions did not result in greater reductions in depression or anxiety symptoms compared with a single-session brief intervention . Further work should focus on the efficacy and role of brief interventions , and addressing smoking and alcohol misuse in cardiac patients with depression One hundred six postmyocardial infa rct ion subjects who either achieved a mean work load of less than seven mets on treadmill testing , who were rated as anxious and /or depressed , or who met both criteria , participated in a controlled study comparing the rehabilitation effectiveness of exercise therapy and group counseling . Each intervention lasted 12 weeks . Follow-up evaluations were scheduled at three months , six months and one year . Exercise substantially increased mean work capacity , decreased fatigue , lessened anxiety and depression , and promoted independence and sociability .  Counseling substantially reduced depression and promoted a sense of friendliness , and decreased interpersonal friction as well as greater independence and sociability . The control group reported no substantial change on any measured factor . Neither counseling nor exercise had an effect on mortality though subjects in the exercise group reported fewer major cardiovascular sequelae Background : Stress reduction and comprehensive lifestyle modification programs have improved atherosclerosis and cardiac risk factors in earlier trials . Little is known about the impact of such programs on quality -of-life ( QoL ) and psychological outcomes . Given recent significant improvements in cardiac care , we evaluated the current benefit of stress reduction/lifestyle modification on QoL and emotional distress in patients with coronary artery disease ( CAD ) . Methods : 101 patients ( 59.4 ± 8.6 years , 23 female ) with CAD were r and omized to a 1-year lifestyle/stress management program ( n = 48 ) or written advice ( n = 53 ) . QoL and psychological outcomes were assessed with the SF-36 , Beck Depression , Spielberger State/Trait Anxiety , Spielberger State/Trait Anger and Perceived Stress Inventories . Group repeated- measures analyses of variance were performed for all measures . Results : Adherence to the program was excellent ( daily relaxation practice 39 ± 5vs . 5 ± 8 min , respectively ; p < 0.001 ) . Both groups improved comparably in most dimensions of QoL , and significantly greater improvements for the lifestyle group were found for physical function and physical sum score ( p = 0.046 and p = 0.045 ) . Depression , anxiety , anger and perceived stress were reduced similarly in both groups . However , intervention × gender interaction effects revealed greater benefits among women in the lifestyle intervention vs. advice group for depression and anger ( p = 0.025 and p = 0.040 ) , but no effects for men . Conclusions : A comprehensive lifestyle modification and stress management program did not improve psychological outcomes in medically stable CAD patients . The program did appear to confer psychological benefits for women but not men . Further trials should investigate gender-related differences in coronary patient responses to behavioral interventions Background : Little is known about the impact of interventions targeting chronic stress levels on clinical outcomes among myocardial infa rct ion ( MI ) patients with increased levels of stress . Objectives : To examine the impact of the addition of brief strategic therapy ( BST ) to usual care ( UC ) on clinical outcomes in first MI patients with increased levels of stress . Design : Eighty-one patients were r and omly assigned to  BST in conjunction with UC ( medical treatment , risk factor information , and guidance on unhealthy behavior change ) or to UC . Methods : The outcome measures were scores on the Perceived Stress Scale , reinfa rct ion and cardiac mortality rates , and scores on the Health Survey . Measures were taken before , post-treatment , and at two follow-ups . Results : Patients subjected to BST showed reduced perceived stress at post-treatment and maintained decreased levels at follow-ups . At 1-year follow-up , they had a lower rate of non-fatal reinfa rct ion , and at 2.5-year follow-up , they had a lower rate of fatal reinfa rct ion . Their mental and physical health was improved at post-treatment and this was sustained at follow-ups . Conclusion : The addition of BST to UC favorably influences the disease course after MI in patients with increased levels of stress BACKGROUND Depressive symptoms are an established predictor of mortality and major adverse cardiac events ( defined as nonfatal myocardial infa rct ion or hospitalization for unstable angina or urgent/emergency revascularizations ) in patients with acute coronary syndrome ( ACS ) . This study was conducted to determine the acceptability and efficacy of enhanced depression treatment in patients with ACS . METHODS A 3-month observation period to identify patients with ACS and persistent depressive symptoms was followed by a 6-month r and omized controlled trial . From January 1 , 2005 , through February 29 , 2008 , 237 patients with ACS from 5 hospitals were enrolled , including 157 persistently depressed patients r and omized to intervention  ( initial patient preference for problem-solving therapy and /or pharmacotherapy , then a stepped-care approach ; 80 patients ) or usual care ( 77 patients ) and 80 nondepressed patients who underwent observational evaluation . The primary outcome was patient satisfaction with depression care . Secondary outcomes were depressive symptom changes ( assessed with the Beck Depression Inventory ) , major adverse cardiac events , and death . RESULTS At the end of the trial , the proportion of patients who were satisfied with their depression care was higher in the intervention group ( 54 % of 80 ) than in the usual care group ( 19 % of 77 ) ( odds ratio , 5.4 ; 95 % confidence interval [ CI ] , 2.2 - 12.9 [ P < .001 ] ) . The Beck Depression Inventory score decreased significantly more ( t(155 ) = 2.85 [ P = .005 ] ) for intervention patients ( change , -5.7 ; 95 % CI , -7.6 to -3.8 ; df = 155 ) than for usual care patients ( change , -1.9 ; 95 % CI , -3.8 to -0.1 ; df = 155 ) ; the depression effect size was 0.59 of the st and ard deviation . At the end of the trial , 3 intervention patients and 10 usual care patients had experienced major adverse cardiac events ( 4 % and 13 % , respectively ; log-rank test , chi(2)(1 ) = 3.93 [ P = .047 ] ) , as well as 5 nondepressed patients ( 6 % ) ( for the intervention vs nondepressed cohort , chi(2)(1 ) = 0.48 [ P = .49 ] ) . CONCLUSION Enhanced depression care for patients with ACS was associated with greater satisfaction , a greater reduction in depressive symptoms , and a promising improvement in prognosis . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00158054 A health education and counselling programme was offered to myocardial infa rct ion patients during and after hospitalization . A r and omized pre-test-post-test control group design was used to evaluate the effects of the experimental intervention . During hospitalization the intervention consisted of two individual counselling sessions and two group health education sessions focusing on medication , healthy habits , anxiety and depression . On completion of these sessions , weekly telephone calls were made to patients for a period of six weeks after discharge from hospital . The intervention was offered to 30 myocardial infa rct ion patients and their partners ( the experimental group ) in addition to  st and ard medical care . Thirty control patients received st and ard medical care only . Two months after myocardial infa rct ion , patients in the experimental condition reported a significantly greater increase in physical activity , and a significantly greater decrease in unhealthy eating habits . No effects were found regarding smoking cessation , anxiety and depression . Twelve months after discharge from hospital patients in the experimental condition reported a significantly greater decrease in unhealthy eating habits . No effects were found regarding smoking cessation , physical activity , anxiety and depression . In addition , two months after myocardial infa rct ion , it was found that patients whose partners participated in the health education sessions showed a significantly greater decrease in smoking and unhealthy eating habits and a significantly greater increase in physical activity than patients with no partner participating . Twelve months after discharge the only significant result favouring the patients whose partner participated in the health education sessions concerned smoking cessation Background Psychosocial stress may play a causative role in development and progression of coronary artery disease ( CAD ) . Purpose We investigated the effects of a 1-year stress management program on daily stress behavior and social support among female CAD patients . Method Women , 247 ( ≤75 years ) , hospitalized for a cardiac event were r and omized to either a control or an intervention group . Controls obtained usual health care ; intervention patients participated in 20 2-h group sessions of stress management therapy and obtained health care by a cardiologist . Measurements were at baseline , 10 weeks ( after ten sessions ) , 1-year ( end of intervention ) , and at a 1- to 2-year follow-up . Results Daily stress scores for the intervention and control groups were at baseline 39.5 ± 8.1 vs. 37.2 ± 9.1 ( p = 0.06 ) , 10 weeks 37.2 ± 8.0 vs. 35.5 ± 9.4 ( p = 0.20 ) , 1-year 36.1 ± 7.2 vs. 35.9 ± 8.5 ( p = 0.85 ) , and at 1–2 year follow-up 34.0 ± 7.8 vs. 35.3 ± 8.7 ( p = 0.32 ) , respectively . Intention to treat analyses showed interaction between treatment and time [ F(3,213 ) = 2.72 ; p = 0.01 ] reflecting that the decrease was more pronounced in the intervention group . There was no evidence for a difference in change concerning social support . Conclusion CAD women in the intervention group had a more pronounced reduction of self-rated daily stress behavior over time compared to controls . However , as the intervention group had higher baseline values , due to regression toward the mean , we have no evidence that the difference in decrease of daily stress was due to the intervention BACKGROUND Psychosocial factors are independently associated with increased risk of cardiovascular disease ( CVD ) morbidity and mortality , but the effects of psychosocial factor intervention on CVD are uncertain . We performed a r and omized controlled clinical trial of cognitive behavioral therapy ( CBT ) to measure its effects on CVD recurrence . METHODS The study included 362 women and men 75 years or younger who were discharged from the hospital after a coronary heart disease event within the past 12 months . Patients were r and omized to receive traditional care  ( reference group , 170 patients ) or traditional care plus a CBT program ( intervention group , 192 patients ) , focused on stress management , with 20 two-hour sessions during 1 year . Median attendance at each CBT session was 85 % . Outcome variables were all-cause mortality , hospital admission for recurrent CVD , and recurrent acute myocardial infa rct ion . RESULTS During a mean 94 months of follow-up , the intervention group had a 41 % lower rate of fatal and nonfatal first recurrent CVD events ( hazard ratio [ 95 % confidence interval ] , 0.59 [ 0.42 - 0.83 ] ; P = .002 ) , 45 % fewer recurrent acute myocardial infa rct ions ( 0.55 [ 0.36 - 0.85 ] ; P = .007 ) , and a nonsignificant 28 % lower all-cause mortality ( 0.72 [ 0.40 - 1.30 ] ; P = .28 ) than the reference group after adjustment for other outcome -affecting variables . In the CBT group there was a strong dose-response effect between intervention group attendance and outcome . During the first 2 years of follow-up , there were no significant group differences in traditional risk factors . CONCLUSIONS A CBT intervention program decreases the risk of recurrent CVD and recurrent acute myocardial infa rct ion . This may have implication s for secondary preventive programs in patients with coronary heart disease . Trial Registration clinical trials.gov Identifier : NCT00888485 & NA ; The Recurrent Coronary Preventive Project ( RCPP ) demonstrated that the addition of Type A counseling to st and ard cardiac counseling result ed in significant reductions in Type A behavior and in a 44 % reduction in reinfa rct ion in post‐myocardial infa rct ion patients . The purpose of the present study was to describe the specific behavioural and psychosocial changes that occurred during this Type A treatment . Patients undergoing Type A counseling  showed significant reductions not only in Type A behavior , but also in the Type A components of hostility , time urgency , and impatience , when compared with patients in the cardiac control group . They also showed significant decreases in depression and anger , and gains in self‐efficacy , and marginally significant gains in social support and well‐being . Type A counseling result ed in a dose‐response relationship with most psychosocial outcomes , such that an increasing amount of treatment contacts was associated with increasing change . These data are important in that they specify a range of psychosocial factors that were influenced by treatment . These factors can be considered to be among the possible explanations for the efficacy of the RCPP treatment on the reduction of cardiac recurrences PURPOSE This r and omized controlled study aim ed to evaluate the effects on psychosocial variables of a 1-year group-based cognitive-behavioral stress management program developed specifically for women with ischemic heart disease . METHODS The present explanatory ( per protocol ) analyses include 80 women who were r and omized to a 1-year cognitive-behavioral stress management program and 86 who were r and omized to usual care ( age = 35 - 77 years ) . Data were obtained before r and omization and after 1 year , when the intervention group had completed the program . RESULTS There were no statistically significant differences between the intervention and usual care groups in the psychosocial endpoints at r and omization . Both groups improved in all psychosocial variables during the 1-year study period , but the rate of improvement was significantly greater in the intervention group for self-rated stress behavior ( P = .006 ) and vital exhaustion ( P = .03 ) . Although changes were in favor of the treatment group also for depressive mood and quality of life , the rates of improvement between the 2 groups did not reach statistical significance ( P = .23 and P = .10 , respectively ) . CONCLUSION A 1-year cognitive-behavioral stress management program design ed specifically for women improved psychological well-being in some aspects in comparison with usual care BACKGROUND Previous studies on cognitive and interpersonal interventions have yielded inconsistent results in ischemic heart disease patients . METHODS 101 patients aged ≤ 70 years , and enrolled one week after complete revascularization with urgent/emergent angioplasty for an AMI , were r and omized to st and ard cardiological therapy plus short-term humanistic-existential psychotherapy ( STP ) versus st and ard cardiological therapy only . Primary composite end point was : one-year incidence of new cardiological events ( re-infa rct ion , death , stroke , revascularization , life-threatening ventricular arrhythmias , and the recurrence of typical and clinical ly significant angina ) and of clinical ly significant new comorbidities . Secondary end points were : rates for individual components of the primary outcome , incidence of re-hospitalizations for cardiological problems , New York Heart Association class , and psychometric test scores at follow-up . RESULTS 94 patients were analyzed at one year . The two treatment groups were similar across all baseline characteristics . At follow-up , STP patients had had a lower incidence of the primary endpoint , relative to controls ( 21/49 vs. 35/45 patients ; p=0.0006 , respectively ; NNT=3 ) ; this benefit was attributable to the lower incidence of recurrent angina and of new comorbidities in the STP group ( 14/49 vs. 22/45 patients , p=0.04 , NNT=5 ; and 5/49 vs. 25/45 , p<0.0001 , NNT=3 , respectively ) . Patients undergoing STP also had statistically fewer re-hospitalizations , a better NYHA class , higher quality of life , and lower depression scores . CONCLUSION Adding STP to cardiological therapy improves cardiological symptoms , quality of life , and psychological and medical outcomes one year post AMI , while reducing the need for re-hospitalizations . Larger studies remain necessary to confirm the generalizability of these results . CLINICAL TRIAL REGISTRATION Clinical Trial.gov : NCT00769366 The psychological impact of exercise training and relaxation therapy was investigated in 156 myocardial infa rct ion patients . They were r and omly assigned to either exercise plus relaxation and breathing therapy ( Treatment A : n = 76 ) or exercise training only ( Treatment B : n = 80 ) . Patients in Treatment A improved on three out of eight psychological measurements ( anxiety , well-being , feelings of invalidity ) . No change was demonstrable in Treatment B. The difference between the treatments was significant for wellbeing ( p less than 0.005 ) . Physical outcome , measured by exercise testing was positive in about half of the patients ( Treatment A : 55 % , Treatment B : 46 % ) . A negative outcome occurred less in Treatment A ( p less than 0.05 ) . Training success was not associated with psychic benefit . The association differed for the two treatments . It was concluded that exercise training was effective for some but not for all cardiac patients , and that a psychic effect of exercise could not be demonstrated . Relaxation therapy enhanced physical and psychic outcome of rehabilitation Objective : The objective of this study was to evaluate the effectiveness of a telephone-based intervention on psychological distress among patients with cardiac illness . Methods : We recruited hospitalized patients surviving an acute coronary syndrome with scores on the Hospital and Anxiety Depression Scale ( HADS ) indicating mild to severe depression and /or anxiety at 1 month postdischarge . Recruited patients were r and omized into either an intervention or control group . Intervention patients received up to six 30-minute telephone-counseling sessions focused on identifying cardiac-related fears . Control patients received  usual care . For both groups , we collected patients ’ responses to the HADS and to the Global Improvement ( CGI-I ) subscale of the Clinical Global Impressions ( CGI ) Scale at baseline and at 2 , 3 , and 6 months postbaseline using Interactive Voice Recognition ( IVR ) technologies . We used mixed-effects analysis to estimate patients ’ changes in CGI-I measures over the three time points of data collection postbaseline . Results : We enrolled 100 patients , and complete CGI-I measures were collected for 79 study patients . The mean age was 60 years ( st and ard deviation = 10 ) , and 67 % of the patients were male . A mixed-effects analysis confirmed that patients in the intervention group had significantly greater improvements in self-rated health ( SRH ) between baseline and month 3 than the control group ( p = .01 ) . Between month 3 and month 6 , no significant differences in SRH improvements were observed between the control and intervention groups . Conclusions : Study patients reported greater SRH improvement result ing from the telephone-based intervention compared with control subjects . Future research should include additional outcome measures to determine the effect of changes in SRH on patients with comorbid physical and emotional disorders . ACS = acute coronary syndrome ; ADL = activities of daily living ; CAD = coronary artery disease ; CGI = Clinical Global Impressions Scale ; CGI-I = Global Improvement subscale of the Clinical Global Impressions ( CGI ) Scale ; ENRICHD = Enhancing Recovery in Heart Disease Patients trial ; HADS = Hospital and Anxiety Depression Scale ; HTS = Healthcare Technology Systems ; ICD-9 = International Classification of Diseases , Ninth Edition ; IRB = Institutional Review Boards ; IVR = interactive voice recognition ; MI = myocardial infa rct ion ; SADHART = the Sertraline Antidepressant Heart Attack R and omized Trial ; SRH = self-rated health Introduction : Patients with cardiovascular disease who stop smoking lower their risk of subsequent morbidity and mortality . However , patients who have suffered a myocardial infa rct ion ( MI ) are more likely to be depressed than the general population , which may make smoking cessation more difficult . Poor social support may also make smoking cessation more difficult for some patients . This study examines the effect of cognitive behavior therapy ( CBT ) for depression , low perceived social support or both on smoking behavior in post-MI patients . Methods : Participants were 1233 patients with a history of smoking enrolled in the Enhancing Recovery in Coronary Heart Disease Patients ( ENRICHD ) trial who provided 7-day point-prevalence smoking behavior information at baseline and at two or more follow-up assessment s. The ENRICHD trial enrolled post-MI patients with depression , low perceived social support or both . Participants were r and omly assigned to either CBT intervention or usual care . We used mixed effects models to accommo date data from multiple smoking point-prevalence measures for each individual participant . Results : CBT did not significantly reduce post-MI smoking across all intervention patients with a history of smoking . However , CBT did reduce post-MI smoking among the subgroup of depressed patients with adequate perceived social support ( OR , 0.68 ; 95 % CI , 0.47–0.98 ) . Conclusion : CBT for depression without more specific attention to smoking cessation may have little overall value as a strategy for helping post-MI patients refrain from smoking . However , use of CBT to treat depression may have the gratuitous benefit of reducing smoking among some post-MI patients . ENRICHD = Enhancing Recovery in Coronary Heart Disease Patients ; MI = myocardial infa rct ion ; CBT = cognitive behavioral therapy ; LPSS = low perceived social support ; MDD = major depressive disorder ; BDI = Beck Depression Inventory ; OR = odds ratio Psychosocial factors affect the development of coronary heart disease and morbidity and mortality of patients with known coronary heart disease . A prior study has shown that psychological distress in patients with known coronary heart disease increased medical and economic costs . This study examined the effects of commonly available psychological interventions offered to patients entering cardiac rehabilitation after hospitalization for angina , myocardial infa rct ion , angioplasty , or coronary artery bypass grafting . A total of 380 patients were screened with the Symptom Checklist-90-Revised ( SCL-90-R ) . Those with T-scores > or = 63 ( > or = 91 percentile ) on the General Severity Index ( GSI ) subscale were r and omly assigned to usual care or special intervention . Special intervention included a psychiatric evaluation , plus one to seven sessions of behavioral therapy . The percentage of patients rehospitalized for cardiac symptoms within 12 months of psychological evaluation was 43 % for special intervention and 40 % for usual care ( NS ) . A correction for crossover between the treatment groups result ed in a favorable trend toward intervention , with 35 % of the psychologically treated patients rehospitalized vs. 48 % of the untreated patients ( NS ) . Although there was a nonsignificant reduction of the SCL-90-R 's GSI T-score , the depression score was significantly reduced in the special intervention group BACKGROUND Evidence suggests that breathing and relaxation therapy may influence cardiac events in persons after acute myocardial infa rct ion ( MI ) . The authors studied the effects of breathing and relaxation therapy on rates of cardiac events and cost effectiveness in past MI patients . METHODS Patients ( n = 156 ) were chosen r and omly to receive either exercise training plus relaxation therapy ( relaxation group ; n = 76 ) or exercise training only ( control group ; n = 80 ) . The occurrence of major cardiac events and cardiac rehospitalizations in the two treatment groups was compared . RESULTS At 5-year follow-up , 12 cardiac deaths had occurred , 5 in the relaxation group and 7 in the control group , reinfa rct ion occurred in 10 and 12 patients , and cardiac surgery was performed in 2 and 11 , respectively . In total , 15 ( 20 % ) and 26 ( 33 % ) patients , respectively , experienced at least one cardiac event ( odds ratio [ OR ] for the relaxation group : 0.55 , 95 % confidence interval [ CI ] 0.29 - 1.05 ; adjusted for risk factors OR 0.52 , 95 % CI 0.28 - 0.99 ) . Regarding all cardiac rehospitalizations , in the relaxation group , 30 patients ( 39 % ) had experienced 52 cardiac events , for which the patients were hospitalized for a total of 476 days . In the control group , 38 patients ( 48 % ) had experienced 78 cardiac events ( OR 0.72 ; 95 % CI 0.38 - 1.36 ) , comprising 719 days of hospitalization . The total number of hospitalizations was reduced by 31 % as a result of relaxation instruction . CONCLUSIONS In the long-term , the disease course after myocardial infa rct ion is influenced favorably by giving relaxation therapy in addition to cardiac rehabilitation . The extra costs of the therapy are compensated by a decrease in hospitalization for cardiac problems Objective A number of previous studies addressed the effect of psychological interventions in patients after acute myocardial infa rct ion ( AMI ) , but it is not known whether psychotherapy might be beneficial after medical and interventional therapy of AMI . We design ed a r and omized , controlled study to assess the effects of a short-term psychotherapy ( STP ) on the clinical outcomes of patients who underwent an emergency percutaneous coronary intervention after AMI . Methods One hundred consecutive patients undergoing an emergency percutaneous coronary intervention will be r and omized 1 week after AMI to medical therapy ( control group , C group ) or to medical therapy and STP ( STP group ) . Clinical follow-up visits are scheduled at 6 months , 1 and 5 years , whereas psychometric tests ( Self-Evaluation test , Modified Maastricht Question naire , Social Support Question naire , Recent Life Change Question naire , Beck Depression Inventory , the MacNew Heart Disease Health-Related Quality of Life Question naire , Type D Personality test ) are scheduled 1 week after AMI and at 1 year . The primary outcome measures of the study are the cumulative incidence of new cardiological events ( myocardial reinfa rct ion , death , stroke , life-threatening ventricular arrhythmias , and recurrence of angina ) and the occurrence of new medical disorders . Secondary outcome measures are the incidence of rehospitalizations due to cardiological problems , the prevalence of patients with New York Heart Association class ≥ II , left ventricular function , as assessed by echocardiography , and mean score of psychometric tests in the two groups at follow-up . Conclusion Our study has been planned to obtain an insight into how a STP influences clinical outcomes after interventional and medical treatment of AMI Depression and sub-syndromal depressive symptoms are important predictors of morbidity and mortality after acute coronary syndrome ( ACS ) . Prior trials of depression treatment in post-ACS patients have demonstrated no improvement for event-free survival , and only modest improvement in depression symptoms . These trials have raised a number of important issues regarding timing of depression intervention , acceptability of depression treatment to ACS patients , and safety for subsets of the treated population . This article describes Project COPES ( Coronary Psychosocial Evaluation Studies ) , a multi-center Phase-I r and omized clinical trial . Project COPES uses a patient preference depression treatment that has previously been found acceptable to medical patients , and a 3-month pre-r and omization observation period to insure depression status . The study sample will include 200 post-ACS patients . The primary outcome is patient satisfaction with depression care . Secondary , exploratory aims include the acceptability of depression treatment , reduction in depressive symptoms , and the effects of treatment on two key pathways -- medication adherence and inflammation -- hypothesized to link depression to post-ACS prognosis . These analyses will provide important data to inform subsequent clinical trials with this population BACKGROUND The presence of depression after an acute coronary syndrome ( ACS ) is associated with worse prognosis and lower adherence to risk-reducing behaviors . We reported earlier that an enhanced depression care intervention reduces depression symptoms and major adverse cardiac events . This study evaluates the impact of the depression intervention on health behavior and blood pressure control . METHODS Between 2005 and 2008 , 157 patients who remained persistently depressed 3 months after ACS were r and omized to a 6-month depression intervention ( initial patient preference for problem-solving therapy and /or pharmacotherapy , followed by stepped care ; 80 patients ) or to  usual care ( 77 patients ) . At r and omization , and then 2 , 4 , and 6 months later , patients were asked if they ( 1 ) missed taking their aspirin ; ( 2 ) followed a heart healthy diet ; ( 3 ) exercised regularly ; and ( 4 ) used tobacco products .  Blood pressure was measured before r and omization and 6 months later . RESULTS At the end of the intervention , there was no significant improvement in the percentage of intervention compared to control group patients who adhered to aspirin ( + 3 % versus -1 % , P = .23 ) , followed a healthy diet ( + 10 % versus + 8 % , P = .39 ) , exercised regularly ( + 5 % versus + 4 % , P = .65 ) , abstained from tobacco ( -3 % versus -1 % , P = .77 ) , or had controlled blood pressure ( + 6 % versus + 16 % , P = .26 ) . CONCLUSION Despite improving depression , enhanced depression care after an ACS did not improve health behavior or blood pressure control compared to usual care . Research is needed to test whether adding an adherence intervention to enhanced depression care can improve adherence and cardiovascular prognosis in depressed patients post-ACS Objective : Intervening in depression and /or low perceived social support within 28 days after myocardial infa rct ion ( MI ) in the Enhancing Recovery in Coronary Heart Disease ( ENRICHD ) clinical trial did not increase event-free survival . The purpose of the present investigation was to conduct post hoc analyses on sex and ethnic minority subgroups to assess whether any treatment subgroup is at reduced or increased risk of greater morbidity/mortality . Methods : The 2481 patients with MI ( 973 white men , 424 minority men , 674 white women , 410 minority women ) who had major or minor depression and /or low perceived social support were r and omly allocated to usual medical care or cognitive behavior therapy .  Total mortality or recurrent nonfatal MI ( ENRICHD primary endpoint ) and cardiac mortality or recurrent nonfatal MI ( secondary endpoint ) were analyzed as composite endpoints by group for time to first event using Cox proportional hazards regression . Results : There was a trend in the direction of treatment efficacy for white men for the primary endpoint ( hazard ratio [ HR ] , 0.80 ; 95 % confidence interval , 0.61–1.05 ; p = .10 ) and a significant ( p < .006 , Bonferroni corrected ) effect for the secondary endpoint ( HR , 0.63 ; 95 % CI , 0.46–0.87 ; p = .004 ) . In contrast , the HRs for each of the other three subgroups were nonsignificant . The magnitude of differences in treatment effects between white men and the other subgroups remained significant for the secondary endpoint ( p = .04 ) after adjustment for age , education , living alone , antidepressant use , comorbidity score , cardiac catheterization , ejection fraction , history of hypertension , and major depression . Conclusions : White men , but not other subgroups , may have benefited from the ENRICHD intervention , suggesting that future studies need to attend to issues of treatment design and delivery that may have prevented benefit among sex and ethnic subgroups other than white men PURPOSE The purpose of this research was to assess whether short-term psychotherapy enhances long-term clinical outcomes in patients with a recent acute myocardial infa rct ion ( AMI ) . METHODS Patients ≤70 years old were r and omized within 1 week of their AMI to short-term ontopsychological psychotherapy plus routine medical therapy vs routine medical therapy only . The primary composite outcome was defined as the combined incidence of new cardiovascular events ( re-infa rct ion , death , stroke , revascularization , life-threatening ventricular arrhythmias , and the recurrence of clinical ly significant angina ) and clinical ly significant new comorbidities . Secondary outcome measures were : rates for individual components of the primary composite outcome ; the rate of re-hospitalization for cardiovascular problems ; and New York Heart Association functional class . RESULTS Ninety-four patients were analyzed , translating into 425 patient-years . The 2 treatment groups were similar across baseline characteristics . At 5-year follow-up , psychotherapy patients had a lower incidence of primary outcome , relative to controls ( 77/223 vs 98/202 patient-years , respectively ; P = .035 ; absolute risk reduction = 19 % , number needed to treat = 8) ; this benefit was attributable to the lower incidence of new comorbidities and clinical ly significant angina in the psychotherapy group . Gains in the primary outcome , relative to controls , among psychotherapy patients occurred in the first year and subsequently remained stable over the following 4 years . CONCLUSIONS Adding short-term ontopsychological psychotherapy to routine secondary prevention of myocardial infa rct ion improves clinical outcomes overall up to 5 years post AMI . Study ing time trends may aid in better targeting of psychological interventions during follow-up . Larger studies remain necessary to confirm these results . TRIAL REGISTRATION www . Clinical Trial.gov NCT00769366 Background : Anxiety is frequent in patients with coronary heart disease ( CHD ) and influences the course of the disease , but no r and omized controlled trial has investigated the effects of a psychotherapy intervention in CHD patients with elevated anxiety scores . The main aim of this study was to evaluate the effects of a 6-month psychotherapy intervention on anxiety in this group of patients . Methods : Fifty-two patients ( 61 ± 8.0 years , 14 female ) with CHD and elevated levels of anxiety completed the study after r and omization into a 6-month psychotherapy intervention or a control condition .  Medically eligible patients were screened for anxiety with the Hospital Anxiety and Depression Scale ( HADS ) and were included if they had a score of 8 or higher . Anxiety scores were reevaluated at 6-month follow-up ( after the treatment ) . Results : At 6-month follow-up significant reductions ( intervention group : –2.0 ± 2.3 ; control group : –1.8 ± 2.8 ; p < 0.01 ) were found in both groups in the HADS anxiety scale but no significant differences between the groups were observed . Adjustment for baseline differences and disease severity did not change these results . Conclusions : Our study showed that elevated anxiety scores were reduced over time but there was no statistically significant effect of the psychotherapy intervention in anxious patients with CHD . Changes in the design of the intervention and study might be useful to further investigate this topic in the future Background — Cardiac rehabilitation ( CR ) is the st and ard of care for patients with coronary heart disease . Despite considerable epidemiological evidence that high stress is associated with worse health outcomes , stress management training ( SMT ) is not included routinely as a component of CR . Methods and Results — One hundred fifty-one out patients with coronary heart disease who were 36 to 84 years of age were r and omized to 12 weeks of comprehensive CR or comprehensive CR combined with SMT ( CR+SMT )  , with assessment s of stress and coronary heart disease biomarkers obtained before and after treatment . A matched sample of CR-eligible patients who did not receive CR  made up the no-CR comparison group . All participants were followed up for up to 5.3 years ( median , 3.2 years ) for clinical events . Patients r and omized to CR+SMT exhibited greater reductions in composite stress levels compared with those r and omized to CR alone ( P=0.022 ) , an effect that was driven primarily by improvements in anxiety , distress , and perceived stress . Both CR groups achieved significant , and comparable , improvements in coronary heart disease biomarkers . Participants in the CR+SMT group exhibited lower rates of clinical events compared with those in the CR-alone group ( 18 % versus 33 % ; hazard ratio=0.49 ; 95 % confidence interval , 0.25–0.95 ; P=0.035 ) , and both CR groups had lower event rates compared with the no-CR group ( 47 % ; hazard ratio=0.44 ; 95 % confidence interval , 0.27–0.71 ; P<0.001 ) . Conclusions — CR enhanced by SMT produced significant reductions in stress and greater improvements in medical outcomes compared with st and ard CR . Our findings indicate that SMT may provide incremental benefit when combined with comprehensive CR and suggest that SMT should be incorporated routinely into CR . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00981253
target: Conclusions We found that psychological intervention  improved psychological symptoms and reduced cardiac mortality for people with CHD .
  However , there remains considerable uncertainty regarding the magnitude of these effects and the specific techniques most likely to benefit people with different presentations of CHD
background: Background Although psychological interventions are recommended for the management of coronary heart disease ( CHD ) , there remains considerable uncertainty regarding their effectiveness .