Psychological Distress, Heart-Related Quality of Life, and Follow-up Participation in Outpatient Cardiac Rehabilitation: A Retrospective Longitudinal Cohort Study
This retrospective longitudinal cohort study found that while baseline psychological distress was associated with poorer heart-related quality of life and lower questionnaire follow-up participation among cardiac rehabilitation patients, it did not clearly predict documented early programme dropout.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
Heart disease is more than a mechanical failure of the heart; it is an experience that reshapes how a person moves, feels, and views their future. When the heart struggles, the quality of life often dips, not just because of physical pain, but because of the worry, sadness, and fear that accompany the diagnosis. Doctors have long known that treating the heart requires treating the whole person, which is why cardiac rehabilitation exists. These are structured programs where patients return to the hospital or a clinic for weeks of supervised exercise, education, and support. The goal is to rebuild strength and confidence. However, a critical question remains: does the emotional state a patient brings with them to the program change how well they recover, or whether they even stay in the program long enough to benefit?
A team of researchers in Switzerland recently set out to answer this by looking at real-world data from hundreds of patients. They focused on the link between psychological distress—specifically feelings of depression and anxiety—and two key outcomes: how much a patient's heart-related quality of life improved, and whether they completed the program or filled out the necessary follow-up surveys. The researchers were particularly interested in whether feeling anxious or depressed at the start meant a patient would drop out early, or if it simply meant they were less likely to return for the final check-in. They also wanted to see if these patterns played out differently for men and women, a group that has historically reported lower quality of life scores after heart events.
The study examined 453 adults who entered a nine-week outpatient cardiac rehabilitation program at a hospital in St. Gallen. Before starting, every patient filled out standard questionnaires. These included measures for depression and anxiety, as well as a specific survey called the HeartQoL, which asks people to rate how their heart condition affects their daily physical activities and their emotional well-being. The researchers then tracked these patients for nine weeks, looking at whether they completed the program and whether they returned to fill out the same surveys at the end.
The results painted a clear picture of the relationship between mental state and physical recovery. First, the program worked. For the patients who provided data at the end of the nine weeks, their heart-related quality of life improved significantly. They reported feeling better physically and emotionally, with the most noticeable gains in their ability to perform daily tasks. This improvement happened regardless of whether they started with high or low levels of distress.
However, the starting emotional state did matter in other ways. Patients who reported higher levels of depression or anxiety at the beginning of the program started with lower quality of life scores. More importantly, those with higher distress were significantly less likely to return for the final survey. The data showed that for every step up in distress levels, the odds of missing the follow-up increased. This suggests that while the program itself might be effective, the emotional burden of depression and anxiety can create a barrier to finishing the paperwork or showing up for the final appointment.
Crucially, the researchers found that this emotional barrier did not necessarily mean the patient was quitting the program itself. When they cross-referenced the survey data with official records of who actually left the program early, a surprising distinction emerged. While high distress was linked to missing the final survey, it was not clearly linked to documented early dropout from the rehabilitation sessions. In fact, among the people who did leave the program early, some had still managed to fill out the final survey, while others who stayed in the program did not. This tells us that missing a questionnaire and quitting the program are two different things. A patient might feel too overwhelmed to write down their feelings but still attend their exercise sessions, or they might attend the sessions but lose interest in the surveys.
The study also looked closely at men and women. Women in the program started with lower quality of life scores than men, a pattern seen in other research. However, once the researchers accounted for the levels of depression and anxiety, the gap between men and women narrowed significantly. The improvement over the nine weeks was similar for both sexes, and the influence of distress on the recovery path did not differ between men and women.
One finding stood out as a possibility for future study but remained unproven in this specific analysis. There was a hint that patients with higher anxiety might have seen a slightly different pattern of emotional improvement compared to those with lower anxiety, but the evidence was not strong enough to be certain. It was a borderline result that requires more research to confirm.
The takeaway from this work is that psychological distress is a powerful predictor of whether a patient will engage with the follow-up process, but it is not a reliable predictor of whether they will abandon the physical rehabilitation itself. The researchers emphasize that clinics should not assume a missing survey means a patient has quit. Instead, they suggest that screening for depression and anxiety at the start of a program can help identify patients who might need extra support to stay engaged with the full process, including the final check-ins. By understanding that the emotional struggle is real and affects participation, medical teams can better tailor their approach to ensure that the benefits of cardiac rehabilitation reach the people who need them most.
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