The Psychological Treatment of Cardiac Patients

  • Alena Talbot Ellis
  • Wolfgang LindenEmail author


This chapter is meant to provide an overview of the existing research literature from the vantage point of how it can guide clinical practice in behavioral cardiac care. The authors are clinical psychologists who work as researchers and as clinicians. We have learned that psychologists and other mental health experts working in ­general health settings face a daily need to provide competent patient care even when research findings are not entirely consistent. In this vein, we urge researchers to work together with clinicians to enhance quality of care through research.


Psychological treatment Cardiac patients INTERHEART study Cardiac rehabilitation Anxiety Depression Personality factors Type-A personality Type-D personality Gender Clinical practice 


  1. 1.
    Linden W, Wen FK. Therapy outcome research, social policy and the continuing lack of ­accumulating knowledge. Prof Psychol Res Pract. 1990;21:482-488.CrossRefGoogle Scholar
  2. 2.
    Yusuf S, Hawken S, Ounpuu S, et al. For the INTERHEART study investigators. Effect of modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case control study. Lancet. 2004;364:937-952.PubMedCrossRefGoogle Scholar
  3. 3.
    Strawbridge WJ, Deleger S, Roberts RE, Kaplan GA. Physical activity reduces the risk of ­subsequent depression for older adults. Am J Epidemiol. 2002;156:328-334.PubMedCrossRefGoogle Scholar
  4. 4.
    Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation. 1999;99:2192-2217.PubMedCrossRefGoogle Scholar
  5. 5.
    Sotile WM. Psychosocial Interventions for Cardiopulmonary Patients. Champaign: Human Kinetics; 1996.Google Scholar
  6. 6.
    Haworth JE, Moniz-Cook E, Clark AL, Wang M, Waddington R, Cleland JGF. Prevalence and predictors of anxiety and depression in a sample of chronic heart failure patients with left ventricular systolic dysfunction. Eur J Heart Fail. 2005;7:803-808.PubMedCrossRefGoogle Scholar
  7. 7.
    Kubzansky LD, Kawachi I, Weiss ST, Sparrow D. Anxiety and coronary heart disease: a ­synthesis of epidemiological, psychological, and experimental evidence. Ann Behav Med. 1998;20:47-58.PubMedCrossRefGoogle Scholar
  8. 8.
    Kawachi I, Sparrow D, Vokonas PS, Weiss ST. Symptoms of anxiety and risk of coronary heart disease: the Normative Aging study. Circulation. 1994;90:2225-2229.PubMedCrossRefGoogle Scholar
  9. 9.
    Donker FJS. Cardiac rehabilitation: a review of current developments. Clin Psychol Rev. 2000;20:923-943.PubMedCrossRefGoogle Scholar
  10. 10.
    Koskenvuo M, Kaprio J, Rose RJ, et al. Hostility as a risk factor for mortality and ischaemic heart disease in men. Psychosom Med. 1998;50:330-340.Google Scholar
  11. 11.
    Chaput LA, Adams SH, Simon JA, et al. Hostility predicts recurrent events among postmenopausal women with coronary heart disease. Am J Epidemiol. 2002;156(12):1092-1099.PubMedCrossRefGoogle Scholar
  12. 12.
    Burell G, Ohman A, Sundin O, et al. Modification of the type A behavior pattern in post-­myocardial infarction patients: a route to cardiac rehabilitation. Int J Behav Med. 1994;1:32-54.PubMedCrossRefGoogle Scholar
  13. 13.
    Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, Brutsaert DL. Personality as independent predictor of long term mortality in patients with coronary heart disease. Lancet. 1996;347:417-421.PubMedCrossRefGoogle Scholar
  14. 14.
    Pedersen SS, Denollet J. Type D personality, cardiac events, and impaired quality of life: a review. Eur J Cardiovasc Prev Rehabil. 2003;10:241-248.PubMedCrossRefGoogle Scholar
  15. 15.
    Appels A. Mental precursors of myocardial infarction. Br J Psychiatry. 1990;156:465-471.PubMedCrossRefGoogle Scholar
  16. 16.
    Appels A, Mulder P. Fatigue and heart disease. The association between ‘vital exhaustion’ and past, present and future coronary heart disease. J Psychosom Res. 1989;33:727-738.PubMedCrossRefGoogle Scholar
  17. 17.
    Kop WJ, Hamulyak K, Pernot C, Appels A. Relationship of blood coagulation and fibrinolysis to vital exhaustion. Psychosom Med. 1997;60:352-358.Google Scholar
  18. 18.
    Appels A, Bar F, Lasker J, Flamm U, Kop W. The effect of a psychological intervention ­program on the risk of a new coronary event after angioplasty: a feasibility study. J Psychosom Res. 1997;43(2):209-217.PubMedCrossRefGoogle Scholar
  19. 19.
    Appels A, Bär F, van der Pol G. Effects of treating exhaustion in angioplasty patients on new coronary events: results of the randomized exhaustion intervention trial (EXIT). Psychosom Med. 2005;67:217-223.PubMedCrossRefGoogle Scholar
  20. 20.
    Schwartz AR, Gerin W, Davidson KW, et al. Toward a causal model of cardiovascular responses to stress and the development of cardiovascular disease. Psychosom Med. 2003;65:22-35.PubMedCrossRefGoogle Scholar
  21. 21.
    Barnett PA, Spence JD, Manuck SB, Jennings JR. Psychological stress and the progression of carotid artery disease. J Hypertens. 1997;15:49-55.PubMedCrossRefGoogle Scholar
  22. 22.
    Chida Y, Steptoe A. Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: a meta-analysis of prospective evidence. Hypertension. 2010;55:1026-1032.PubMedCrossRefGoogle Scholar
  23. 23.
    Anderson JC, Linden W, Habra ME. The importance of examining blood pressure reactivity and recovery in anger provocation research. Int J Psychophysiol. 2005;57:159-163.PubMedCrossRefGoogle Scholar
  24. 24.
    Lai JY, Linden W. Gender, anger expression style, and opportunity for anger release determine cardiovascular reaction to and recovery from anger provocation. Psychosom Med. 1992;54:297-310.PubMedGoogle Scholar
  25. 25.
    Wang HX, Leineweber C, Kirkeeide R. Psychosocial stress and atherosclerosis: family and work stress accelerate progression of coronary disease in women. The Stockholm Female Coronary Angiography Study. J Intern Med. 2007;261:245-254.PubMedCrossRefGoogle Scholar
  26. 26.
    Kaprio J, Koskenvuo M, Rita H. Mortality after bereavement: a prospective study of 95,647 persons. Am J Public Health. 1987;77:283-287.PubMedCrossRefGoogle Scholar
  27. 27.
    Leor J, Poole WK, Kloner RA. Sudden cardiac death triggered by an earthquake. N Engl J Med. 1996;334:413-419.PubMedCrossRefGoogle Scholar
  28. 28.
    Meisel SR, Kutz I, Dayan KI, et al. Effects of the Iraqi missile war on incidence of acute ­myocardial infarction and sudden death in Israeli civilians. Lancet. 1991;338:660-661.PubMedCrossRefGoogle Scholar
  29. 29.
    Jacob RG, Chesney MA, Williams DM, et al. Relaxation therapy for hypertension: design effects and treatment effects. Ann Behav Med. 1991;13:5-17.Google Scholar
  30. 30.
    Linden W. Stress Management: From Basic Science to Better Practice. Thousand Oaks: Sage; 2005.Google Scholar
  31. 31.
    Linden W, Moseley JV. The efficacy of behavioral treatments for hypertension. Appl Psychophysiol Biofeedback. 2006;31:51-63.PubMedCrossRefGoogle Scholar
  32. 32.
    Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and survival after myocardial infarction: a prospective, population-based study of the elderly. Ann Intern Med. 1992;117:1003-1009.PubMedCrossRefGoogle Scholar
  33. 33.
    Frasure-Smith N, Lesperance F, Gravel G, et al. Social support, depression, and mortality ­during the first year after myocardial infarction. Circulation. 2000;101(16):1919-1924.PubMedCrossRefGoogle Scholar
  34. 34.
    Ahern MM, Hendryx MS. Social capital and risk for chronic illnesses. Chronic Illn. 2005;1:183-190.PubMedGoogle Scholar
  35. 35.
    Hogan B, Linden W, Najarian B. Social support interventions: do they work? Clin Psychol Rev. 2002;22:381-440.CrossRefGoogle Scholar
  36. 36.
    Linden W. Psychological treatments in cardiac rehabilitation: review of rationales and ­outcomes. J Psychosom Res. 2000;48:443-454.PubMedCrossRefGoogle Scholar
  37. 37.
    Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation. 2007;115:2675-2682.PubMedCrossRefGoogle Scholar
  38. 38.
    Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet. 2001;357(9263):1191-1194.PubMedCrossRefGoogle Scholar
  39. 39.
    Writing committee for the ENRICHD investigators. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the enhancing recovery in coronary heart disease patients (ENRICHD) randomized trial. JAMA. 2003;289:3106-3116.CrossRefGoogle Scholar
  40. 40.
    Friedman M, Thoreson C, Gill J, et al. Alteration of type a behavior and reduction in cardiac recurrences in post-myocardial infarction patients. Am Heart J. 1984;108:237-248.PubMedCrossRefGoogle Scholar
  41. 41.
    Frasure-Smith N, Prince R. The ischemic heart disease life stress monitoring program: impact on mortality. Psychosom Med. 1985;47:431-445.PubMedGoogle Scholar
  42. 42.
    Frasure-Smith N, Prince R. Long-term follow-up of the ischemic heart disease life stress ­monitoring program. Psychosom Med. 1989;51:485-513.PubMedGoogle Scholar
  43. 43.
    Frasure-Smith N. In-hospital symptoms of psychological stress as predictors of long-term ­outcome after acute myocardial infarction in men. Am J Cardiol. 1991;67:121-127.PubMedCrossRefGoogle Scholar
  44. 44.
    Frasure-Smith N, Lesperance F, Prince R, et al. Randomised trial of home-based psychosocial nursing intervention for patients recovering from myocardial infarction. Lancet. 1997;350(9076):473-479.PubMedCrossRefGoogle Scholar
  45. 45.
    Cossette S, Frasure-Smith N, Lesperance F. Clinical implications of a reduction in psychological distress on cardiac prognosis in patients participating in a psychosocial intervention ­program. Psychosom Med. 2001;63(2):257-266.PubMedGoogle Scholar
  46. 46.
    Jones DA, West RR. Psychological rehabilitation after myocardial infarction: multicentre ­randomized controlled trial. BMJ. 1996;313(7071):1517-1521.PubMedCrossRefGoogle Scholar
  47. 47.
    Carney RM, Blumenthal JA, Freedland KE, et al. Depression and late mortality after ­myocardial infarction in the Enhancing Recovery in Coronary Heart Disease (ENRICHD) study. Psychosom Med. 2004;66(4):466-474.PubMedCrossRefGoogle Scholar
  48. 48.
    Dusseldorp E, Van Elderen T, Maes S, Meulman J, Kraail V. A meta-analysis of psycho-­educational programs for coronary heart disease patients. Health Psychol. 1999;18:506-519.PubMedCrossRefGoogle Scholar
  49. 49.
    Linden W, Phillips MJ, Leclerc J. Psychological treatment of cardiac patients: a meta analysis. Eur Heart J. 2007;28:2972-2984.PubMedCrossRefGoogle Scholar
  50. 50.
    Nunes EV, Frank KA, Kornfeld DS. Psychological treatment for the type a behavior pattern and for coronary heart disease: a meta-analysis of the literature. Psychosom Med. 1987;48:159-173.Google Scholar
  51. 51.
    Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med. 1996;156(7):745-752.PubMedCrossRefGoogle Scholar
  52. 52.
    van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil. 2005;12(3):193-202.PubMedCrossRefGoogle Scholar
  53. 53.
    Linden W, Satin JR. Avoidable pitfalls in behavioral medicine outcome research. Ann Behav Med. 2007;33:143-147.PubMedCrossRefGoogle Scholar
  54. 54.
    Clark AM, Hartling L, Vandermeer B, McAlister FA. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med. 2005;143:659-672.PubMedCrossRefGoogle Scholar
  55. 55.
    Lau J, Antman E, Jimenez-Silva J, et al. Cumulative meta-analysis of therapeutic trials for myocardial infarction. N Engl J Med. 1992;327:248-254.PubMedCrossRefGoogle Scholar
  56. 56.
    Osevala NM, Malani PN. Cardiac rehabilitation in older adults: benefits and barriers. Clin Geriatr Med. 2008;16:22-24.Google Scholar
  57. 57.
    Ades PA, Waldmann ML, McCann WJ, Weaver SO. Predictors of cardiac rehabilitation ­participation in older coronary patients. Arch Intern Med. 1992;152(5):1033-1035.PubMedCrossRefGoogle Scholar
  58. 58.
    Barber K, Stommel M, Kroll J, et al. Cardiac rehabilitation for community-based patients with myocardial infarction: factors predicting discharge recommendation and participation. J Clin Epidemiol. 2001;54:1025-1030.PubMedCrossRefGoogle Scholar
  59. 59.
    Jackson L, Leclerc J, Erskine Y, Linden W. Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors. Heart. 2005;91:10-14.PubMedCrossRefGoogle Scholar
  60. 60.
    Oldridge NB, Guyatt GH, Fischer ME, Rimm AA. Cardiac rehabilitation after myocardial infarction: combined experience of randomized clinical trials. JAMA. 1988;260:945-950.PubMedCrossRefGoogle Scholar
  61. 61.
    Poole G, Hunt Matheson D, Cox DN. The Psychology of Health and Health Care: A Canadian Perspective. 3rd ed. Toronto: Pearson Prentice-Hall; 2008.Google Scholar
  62. 62.
    Lane D, Carroll D, Ring C, Beevers DG, Lip GYH. Predictors of attendance at cardiac ­rehabilitation after myocardial infarction. J Psychosom Res. 2001;51:497-501.PubMedCrossRefGoogle Scholar
  63. 63.
    Caulin-Glaser T, Maciejewski PK, Snow R, LaLonde M, Mazure C. Depressive symptoms and sex affect completion rates and clinical outcomes in cardiac rehabilitation. Prev Cardiol. 2007;10:15-21.PubMedCrossRefGoogle Scholar
  64. 64.
    Mosca L, Manson JE, Sutherland SE, et al. Cardiovascular disease in women. A statement for healthcare professionals from the American Heart Association. Circulation. 1997;96:2468-2482.PubMedCrossRefGoogle Scholar
  65. 65.
    MacKenzie G. Role patterns and emotional responses of women with ischemic heart disease 4 to 6 weeks after discharge form hospital. Can J Cardiovasc Nurs. 1993;4:9-15.PubMedGoogle Scholar
  66. 66.
    Katz C, Martin RD, Landa B, Chadda KD. Relationship of psychological factors to frequent symptomatic ventricular arrhythmia. Am J Med. 1985;78:589-594.PubMedCrossRefGoogle Scholar
  67. 67.
    Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after ­myocardial infarction. Circulation. 1995;91(4):999-1005.PubMedCrossRefGoogle Scholar
  68. 68.
    Shuster PM, Waldron J. Gender differences in cardiac rehabilitation patients. Rehabil Nurs. 1991;16:248-253.CrossRefGoogle Scholar
  69. 69.
    Abbey SE, Stewart DE. Gender and psychosomatic aspects of ischemic heart disease. J Psychosom Res. 2000;48:417-423.PubMedCrossRefGoogle Scholar
  70. 70.
    Orth-Gomér K, Schneiderman N, Wang HX, Walldin C, Blom M, Jernberg T. Stress reduction prolongs life in women with coronary disease: the Stockholm Women’s Intervention Trial for Coronary Heart Disease (SWITCHD). Circ Cardiovasc Qual Outcomes. 2009;2:25-32.PubMedCrossRefGoogle Scholar
  71. 71.
    Schrader G, Check F, Hordacre AL, Guiver N. Predictors of depression three months after cardiac hospitalization. Psychosom Med. 2004;66:514-520.PubMedCrossRefGoogle Scholar
  72. 72.
    Grissom GR, Phillips RA. Screening for depression: this is the heart of the matter. Arch Intern Med. 2005;165:1214-1215.PubMedCrossRefGoogle Scholar
  73. 73.
    Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity of the hospital anxiety and depression scale: an updated literature review. J Psychosom Res. 2002;52:69-77.PubMedCrossRefGoogle Scholar
  74. 74.
    Young QR, Ignaszewski A, Fofonoff D, Kaan A. Brief screen to identify 5 of the most common forms of psychosocial distress in cardiac patients: validation of the screening tool for psychological distress. J Cardiovasc Nurs. 2007;22:525-534.PubMedGoogle Scholar
  75. 75.
    Ades PA, Pashkow FJ, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil. 1997;17:222-231.PubMedCrossRefGoogle Scholar

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© Springer-Verlag London Limited 2011

Authors and Affiliations

  1. 1.Department of PsychologyUniversity of British ColumbiaVancouverCanada

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