Richards, Suzanne H., Anderson, Lindsey, Jenkinson, Caroline E., Whalley, Ben, Rees, Karen, Davies, Philippa, Bennett, Paul, Liu, Zulian, West, Robert, Thompson, David R. and Taylor, Rod S (2017) Psychological interventions for coronary heart disease. Cochrane Database of Systematic Reviews (4). CD002902. doi:10.1002/14651858.CD002902.pub4 ISSN 1469-493X.

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Abstract

Background:
Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

Objectives:
To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

Search methods:
We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

Selection criteria:
We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

Data collection and analysis:
Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

Main results:
This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.

Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).

There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

Authors' conclusions:
This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

Item Type:	Journal Article
Subjects:	R Medicine > RC Internal medicine
Divisions:	Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School > Health Sciences > Statistics and Epidemiology Faculty of Science, Engineering and Medicine > Medicine > Warwick Medical School
Library of Congress Subject Headings (LCSH):	Coronary heart disease -- Prevention, Coronary heart disease -- Psychological aspects, Systematic reviews (Medical research)
Journal or Publication Title:	Cochrane Database of Systematic Reviews
Publisher:	John Wiley & Sons Ltd.
ISSN:	1469-493X
Book Title:	Cochrane Database of Systematic Reviews
Official Date:	28 April 2017
Dates:	Date Event 28 April 2017 Published 28 April 2017 Accepted
Number:	4
Article Number:	CD002902
DOI:	10.1002/14651858.CD002902.pub4
Status:	Peer Reviewed
Publication Status:	Published
Access rights to Published version:	Open Access (Creative Commons)
Date of first compliant deposit:	13 October 2017
Date of first compliant Open Access:	28 April 2018
Funder:	University of Bristol. Department of Social Medicine, Cardiff University, University of Exeter (UoE). Medical School, Collaborations for Leadership in Applied Health Research and Care (CLAHRC), Royal Devon and Exeter NHS Foundation Trust, University of Leeds. Leeds Institute of Health Sciences, British Heart Foundation, Economic and Social Research Council (Great Britain) (ESRC), National Institute for Health Research Health Technology Assessment (Great Britain) (NIHR HTA), South West General Practice Trust, Heart Group UK, Cochrane Collaboration
Grant number:	PTA-026-27-2113 (ESRC)
RIOXX Funder/Project Grant:	Project/Grant ID RIOXX Funder Name Funder ID UNSPECIFIED University of Bristol. Department of Social Medicine http://dx.doi.org/10.13039/501100000883 UNSPECIFIED Cardiff University http://dx.doi.org/10.13039/501100000866 UNSPECIFIED University of Exeter. Medical School http://dx.doi.org/10.13039/501100000737 UNSPECIFIED Collaborations for Leadership in Applied Health Research and Care (CLAHRC) UNSPECIFIED UNSPECIFIED Royal Devon and Exeter NHS Foundation Trust http://dx.doi.org/10.13039/100009745 UNSPECIFIED University Of Leeds. Institute of Health Sciences http://dx.doi.org/10.13039/501100000777 UNSPECIFIED British Heart Foundation http://dx.doi.org/10.13039/501100000274 PTA-026-27-2113 [ESRC] Economic and Social Research Council http://dx.doi.org/10.13039/501100000269 UNSPECIFIED National Institute for Health Research Health Technology Assessment (Great Britain) (NIHR HTA) UNSPECIFIED UNSPECIFIED South West General Practice Trust UNSPECIFIED UNSPECIFIED Heart Group UK UNSPECIFIED UNSPECIFIED Cochrane Collaboration UNSPECIFIED

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