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Canadian Journal of Cardiology

SEX DIFFERENCES IN THE IMPACT OF SYMPTOMS OF ANXIETY AND DEPRESSION ON CARDIAC REHABILITATION PARTICIPATION AND OUTCOMES

      BACKGROUND

      Cardiac rehabilitation (CR) reduces mortality among patients with coronary artery disease (CAD), yet participation rates are suboptimal particularly among women. Symptoms of anxiety and depression are more common in females with CAD and may interfere with CR participation. This retrospective analysis of data investigated sex differences in psychological distress at CR outset and their influence on CR participation and cardiometabolic outcomes.

      METHODS AND RESULTS

      Data were collected at a large, Canadian outpatient CR clinic between 1996-2016. Patients with CAD were referred to a 12-week exercise-based CR program and attended either an early-CR access stream (i.e., automatic CR referral triggered at hospital discharge post-acute coronary syndrome [ACS] event; “ECAC” stream), or a non-ACS stream (i.e., coronary surgery and other non-ACS CAD referrals; “SPS” stream). Both streams completed an exercise stress test and medical evaluation (cardiometabolic risk factors, cardiorespiratory fitness [CRF], Hospital Anxiety and Depression Scale [HADs]) at CR outset and 12-weeks. HADs scores were dichotomized into “probably clinically-significant” anxiety/depression (HADS ≥11) or mild/no anxiety/depression (HADS < 11). CR completion was defined as attending the 12-week medical evaluation. CR adherence was indicated by the number of exercise sessions attended out of 24. Analyses were stratified by sex and program stream. A total of 2,420 ECAC (18.2% females), and 2,510 SPS patients (21.0% females) were included (Table 1). Across streams, 20% of females reported probably clinically-significant anxiety relative to 10% of males (p < .001); no sex differences were observed in depressive symptoms. CR non-completion was 28-38% in patients with clinically-significant depression/anxiety vs. 20% non-completion in patients with no/mild symptoms (p < .001). This effect was particularly pronounced in females with depressive symptoms (i.e., 40% [SPS] -64% [ECAC] non-completers vs. 29% of males not completing across streams), p's < .05. In contrast, males with probably clinically-significant HADs anxiety or depression attended 1.50-2.0 and 1.75-3.53 fewer CR exercise sessions, respectively, than males with no/mild symptoms, p's < .05. Anxious/depressive symptoms did not predict CR adherence in females. Probably clinically-significant depression (β=-.061, SE=.010; p=.008) or anxiety (β =-.058; SE=.154; p=.011) was associated with lower 12-week CRF in males, but not females (p's>.05).

      CONCLUSION

      Symptoms of psychological distress may exacerbate CR non-completion rates in females. Males with anxious and/or depressive symptoms at CR outset may be at greater risk than females for lower CR exercise adherence; suboptimal adherence is a potential mediator of poorer CRF at 12-weeks. Screening and treating patients with psychiatric symptoms at CR outset may improve CR participation and enhance cardiac health outcomes for both sexes.
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