Levels of depressive symptoms in cardiac patients attending cardiac rehabilitation with a history of depression: pre Covid-19 and Covid-19 period comparison.

BACKGROUND: The large-scale changes in cardiac rehabilitation (CR) programme delivery in response to COVID-19 has led to diminished provision. The influence of these service changes on the depression symptoms of patients in CR programmes is unknown. Our study investigated the extent of depressive symptoms prior to and during the COVID-19 periods in patients with a previous history of depression at the start of CR. METHODS: Use of Registry routine practice data, National Audit of Cardiac Rehabilitation (NACR), from COVID-19 period Feb 2020 and Jan 2021, as well as pre COVID-19 period Feb 2019 and Jan 2020, was extracted. Depressive symptoms were defined according to Hospital Anxiety and Depression Score ≥ 8. Chi-square tests and independent samples t-tests were used to investigate baseline characteristics. Additionally, a binary logistic regression to examine the factors associated with high levels of depressive symptoms. RESULTS: In total 3661 patients with a history of depression were included in the analysis. Patients attending CR during COVID-19 were found to be 11% more likely to have high levels of acute depressive symptoms compared to patients attending CR prior to COVID-19. Physical inactivity, increased anxiety, a higher total number of comorbidities, increased weight, and living in the most deprived areas were statistically significant factors associated with high levels of acute depressive symptoms at the start of CR following multivariate adjustments. CONCLUSION: Our research suggests that following a cardiac event patients with prior history of depression have high levels of acute depressive symptoms at CR baseline assessment. This finding exists in both the pre Covid-19 and Covid-19 periods in patients with a history of depression.

To what extent is multi-morbidity associated with new onset depression in patients attending cardiac rehabilitation?

BACKGROUND: Depression is associated with increased mortality and poor prognosis in patients with cardiovascular disease (CVD). However, little is known about the patient characteristics associated with new onset post heart event depressive symptoms, specifically medical comorbidities, among cardiac rehabilitation (CR) participants. Therefore, this paper examines the comorbidity profile and characteristics associated with new onset depressive symptoms in patients attending CR. METHODS: An observational study using the routine practice data of British Heart Foundation National Audit of Cardiac Rehabilitation (NACR) from the last six years between April 2012 and March 2018. Patients with new onset post heart event depression and no previous documented history of depression were selected as the study population. An independent samples t-test and chi square tests were used to compare the association between new onset depressive symptoms and patient variables including demographics, clinical measures and comorbidities. A binary logistic regression was conducted to investigate the predictors of new onset depressive symptoms employing log-likelihood ratio statistic. RESULTS: The analyses included 109,055 CR patients with new onset depression measured by Hospital Anxiety and Depression Scale (HADS). At baseline assessment, comorbidity measures associated with new onset depressive symptoms were increased total number of comorbidities and a range of comorbidities - including diabetes, angina, arthritis, chronic back problems, asthma, stroke, anxiety, rheumatism, claudication, osteoporosis, chronic bronchitis and emphysema. After multivariate adjustments were done, at the start of CR, the significant predictors of new onset depressive symptoms were physical inactivity, high HADS anxiety score measurement, increased weight, total number of comorbidities, diabetes, stroke, chronic back problems, being from areas with higher levels of social deprivation, being single, and male. CONCLUSION: The research findings establish new insights into the association between patient demographic and clinical variables across a range of comorbidities in patients with new onset post heart event depressive symptoms. At the start of CR, patients with new onset depressive symptoms need to be assessed skilfully as they tend to have a complex multi-morbid presentation linked to psychosocial risk factors known to hinder CR engagement.

Factors associated with acute depressive symptoms in patients with comorbid depression attending cardiac rehabilitation.

BACKGROUND: The literature suggests that comorbid depression, defined in this paper as a history of depression prior to a cardiovascular event, has an impact on later onset depression as well as constituting increased risk of mortality and adverse cardiac events. However, which factors are associated with depression, specifically in patients with comorbid depression, is unclear. Therefore, this paper investigates the factors associated with depression in patients with comorbid depression attending cardiac rehabilitation (CR). METHODS: This observational study used routinely collected data from the British Heart Foundation National Audit of Cardiac Rehabilitation for the time period between April 2012 and March 2017. CR participants with comorbid depression were selected as the study population. An independent t-test and chi-square test were used to compare the association between acute depression symptoms and baseline characteristics in this population. RESULTS: A total of 2715 CR patients with comorbid depression were analysed. Characteristics associated with acute depressive symptoms in patients with comorbid depression were found to be: young age (MD: 2.71, 95% CI 1.91, 3.50), increased number of comorbidities (MD: -0.50, 95% CI -0.66, - 0.34), increased weight (MD: -1.94, 95% CI -3.35, - 0.52), high BMI (MD: -1.94, 95% CI -3.35, - 0.52), HADS anxiety (MD: -5.17, 95% CI -5.47, - 4.87), comorbid anxiety (52.4%, p <  0.001), physical inactivity (150 min moderate physical activity a week and 75 min vigorous exercise a week; 27.5%, p <  0.001; 5.6%, p <  0.001 respectively), smoking (12.7%, p <  0.001), and being less likely to be partnered (63.6%, p <  0.001). CONCLUSION: The study demonstrated the association between a variety of clinical and socio-demographic factors and depression. The findings of the research indicated that, at CR baseline assessment, caution must be taken with patients with comorbid depression, specifically those with higher level depressive symptoms at the start of rehabilitation. Furthermore, their multi-comorbid condition must also be taken into account. Patients with higher depression symptoms and comorbid depression scored five points higher on the HADS anxiety scale in comparison to patients with lower level depression symptoms at the start of CR, which demonstrated that anxiety and depression are interrelated and present together.

What are the determinants of change in walking fitness in patients with a history of depression following cardiac rehabilitation?

AIMS: This study aims to investigate the demographic, clinical and service level factors determining change in walking fitness in cardiac rehabilitation (CR) patients with a history of depression following the CR programme. METHODS AND RESULTS: National Audit of Cardiac Rehabilitation (NACR) clinical data were used to identify 1476 patients with a history of depression who had their pre and post incremental shuttle walk test (ISWT) recorded between 1st Jan 2016 and 31st Jan 2020. A multiple linear regression was conducted to examine the determinants of change in walking fitness (m) following CR. Mean age was 61 (SD 10.45) and mean ISWT distance at baseline and outcome were 352.06m (SD 169.48) and 463.43m (SD 197.65), respectively. Multivariate analysis revealed that change in walking distance reduced by 1.6m for each year increase in age at baseline (P < 0.001). Females and unemployed patients had less improvement in walking fitness (23.1m and 21.5m, respectively). Having a body mass index >30 was associated with lower improvement (24.2m, p < 0.001), while physically active patients had 14.6m higher change. Higher baseline ISWT quintiles were associated with less improvement, and increased waiting time to start CR was associated with reduced change in walking fitness following CR. CONCLUSION: Older age, female gender, unemployment, higher baseline BMI, longer waiting time, and lower physical activity were associated with reduced walking fitness improvement in patients with a history of depression. Targeted intervention and prompt access to CR can optimize outcomes.

Factors associated with new-onset depressive symptoms in patients starting cardiac rehabilitation: Pre-COVID-19 and COVID-19 period comparison.

OBJECTIVE: We aim to: 1) investigate whether starting cardiac rehabilitation (CR) during the COVID-19 period was influential on new-onset depressive symptoms, 2) examine the relationship between sociodemographic and medical factors with the new-onset of depressive symptoms before and during the COVID-19 period in UK patients commencing CR. METHODS: The national audit of cardiac rehabilitation (NACR) data were used and the two years of data before COVID-19 and during COVID-19 were analysed (Feb,2018 - Nov,2021). Hospital Anxiety and Depression Scale measurement was used to assess depressive symptoms. Bivariate analysis and logistic regression were conducted to examine the influence of the COVID-19 period on new-onset depressive symptoms and the patient characteristics associated with it. RESULTS: 71055 patients screened for new-onset depressive symptoms were included in the analysis. Based on multivariate analysis, patients commencing CR during COVID-19 were 8% more likely to have new onset depressive symptoms compared to patients commencing before COVID-19. Smoking (OR: 1.26, 95%CI: 1.11, 1.43), physical inactivity (OR: 1.86, 95%CI: 1.74, 1.98), high anxiety (OR: 1.45, 95%CI: 1.44, 1.46), being male (OR: 1.21, 95%CI: 1.12, 1.30), single (OR: 1.25, 95%CI: 1.16, 1.35), having comorbidities of arthritis, diabetes, chronic bronchitis, emphysema, claudication (OR range: 1.19 to 1.60), receiving CABG treatment (OR: 1.47, 95%CI: 1.25, 1.73), and having heart failure (OR: 1.33, 95%CI: 1.19, 1.48) were the factors associated with having new-onset depressive symptoms at the start of CR. CONCLUSION: Our findings have shown that starting CR during the COVID-19 period was associated with increased odds of having new-onset depressive symptoms.

Is improvement in depression in patients attending cardiac rehabilitation with new-onset depressive symptoms determined by patient characteristics?

BACKGROUND: Patients with cardiovascular disease (CVD) commonly experience depressive symptoms which is associated with adverse outcome and increased mortality. Examining the baseline characteristics of cardiac rehabilitation (CR) patients that determine Hospital Anxiety and Depression Scale (HADS) depression outcome may facilitate adjustments in CR programme delivery. This study aims to investigate whether comorbidities, demographic and clinical characteristics of patients, with new-onset post-cardiac event depressive symptoms, determine change in their depression following CR. METHODS: Analysing the routine practice data of British Heart Foundation National Audit of Cardiac Rehabilitation between April 2012 and March 2018, an observational study was conducted. Patients with new-onset post-cardiac event depressive symptoms and no previous documented history of depression constituted the study population. RESULTS: The analyses included 64 658 CR patients (66.24±10.69 years, 75% male) with new-onset HADS measures, excluding patients with a history of depression. The comorbidities determining reduced likelihood of improvement in depression outcomes after CR were angina, diabetes, stroke, emphysema and chronic back problems. In addition, higher total number of comorbidities, increased weight, a higher HADS anxiety score, smoking at baseline, physical inactivity, presence of heart failure and being single were other significant determinants. However, receiving coronary artery bypass graft treatment was associated with better improvement. CONCLUSION: The study identified specific baseline comorbid conditions of patients with new-onset depressive symptoms including angina, diabetes, stroke, emphysema and chronic back problems that were determinants of poorer mental health outcomes (HADS) following CR. Higher total number of comorbidities, increased weight, physical inactivity, smoking, presence of heart failure and being single were other determinants of a negative change in depression. These findings could help CR programmes focus on tailoring the CR intervention around comorbidity, physical activity status, weight management and smoking cessation in patients with new-onset depressive symptoms.

Determinants of depression in patients with comorbid depression following cardiac rehabilitation.

Background: A prior history of depression, at the point patients start cardiac rehabilitation (CR), is associated with poor outcomes; however, little is known about which factors play a part in determining the extent of benefit following CR. Therefore, we aim to identify and evaluate determinants of CR depression outcomes in patients with comorbid depression. Methods: An observational study of routine practice using the British Heart Foundation National Audit of Cardiac Rehabilitation data between April 2012 and March 2017. Baseline characteristics were examined with independent samples t-test and χ2 test. A binary logistic regression was used to predict change in depression outcome following CR. Results: The analysis included 2715 CR participants with depression history. The determinants of Hospital Anxiety and Depression Scale (HADS) depression measurement post-CR were higher total number of comorbidities (OR 0.914, 95% CI 0.854 to 0.979), a higher HADS anxiety score (OR 0.883, 95% CI 0.851 to 0.917), physical inactivity (OR 0.707, 95% CI 0.514 to 0.971), not-smoking at baseline (OR 1.774, 95% CI 1.086 to 2.898) and male gender (OR 0.721, 95% CI 0.523 to 0.992). Conclusion: Baseline characteristics of patients with comorbid depression such as higher anxiety, higher total number of comorbidities, smoking, physical inactivity and male gender were predictors of their depression levels following CR. CR programmes need to be aware of comorbid depression and these related patient characteristics associated with better CR outcomes.