BEHAVIORAL AND MOOD CHANGES IN RESPONSE TO CARDIAC REHABILITATION. A Thesis Presented to. The faculty of. The College of Arts and Sciences

Transcription

1 BEHAVIORAL AND MOOD CHANGES IN RESPONSE TO CARDIAC REHABILITATION A Thesis Presented to The faculty of The College of Arts and Sciences Ohio University In Partial Fulfillment of the Requirements for Graduation with Honors in Psychology by Molly McKenzie Long May 2014

2 1 Table of Contents Abstract...3 Behavioral and Mood Changes in Response to Cardiac Rehabilitation.5 Mood Fitness...6 Predictors of Change Heart History...10 Specific Aims.. 11 Method..12 Participants.. 12 Procedure Measures Mood and General Health.13 Fitness...14 Body Composition 15 Cardiac History.15 Statistical Analysis.. 16 Results...17 Baseline Characteristics Mood and General Health Changes Physical Changes Predictors of Change...20

3 2 Heart History: Composite Score of Severity.21 Heart History: Individual Predictors.21 Mood Predictors 22 Fitness Predictors..25 Discussion.27 References.33

4 3 Abstract Evidence suggests that depression and anxiety are commonly experienced by patients with heart disease. In response to cardiac rehabilitation (CR), behavioral and mood improvements may occur due to stress, and exercise training. The two main goals of this study were to assess mood (e.g., depression) and behavioral changes (e.g., fitness) through the CR process and test if these potential changes were predicted by heart history. Heart history may predict better or worse improvements from preprogram to post program. We were also interested in additional possible predictors of outcome post CR, such as mood and fitness. It was expected that mood and fitness would improve throughout CR. To test these aims, 75 medical records from patients enrolled in HeartWorks CR Program in Athens, Ohio, were reviewed as a withingroup design. The HeartWorks program provided exercise and relaxation training to its patients over a 12-week period. Records of prior patients were coded for presence of depressed mood, physical and mental health status, exercise, and stress management pre and post CR. Depression and six of the eight general health scores significantly improved from pre to post CR. Physical measures that improved were weight, physical fitness, and waist circumference. Overall severity of heart history did not predict outcomes but individual events (e.g., stents) predicted change. Number of myocardial infarctions positively predicted body mass index and negatively predicted physical-functioning. Number of coronary artery bypass grafts negatively predicted the emotional struggles. The number of stents negatively predicted vitality and mental

5 4 health. With this information, we might improve CR by attending to specific populations and focusing on areas that did not improve after CR. Keywords: anxiety, cardiac rehabilitation, coronary artery bypass graft, depression, fitness, myocardial infarction, stent

6 5 Behavioral and Mood Changes in Response to Cardiac Rehabilitation Cardiac Rehabilitation (CR) Programs are geared toward patients who have experienced cardiac events such as myocardial infarctions, stents, coronary artery bypass grafts (CABG), and/or angina. CABG is a type of revascularization used with complex coronary artery disease (Mohr, 2013). This allows the healthy artery to bypass the blocked artery, creating a new path for blood to flow through. Percutaneous coronary intervention (PCI), also known as coronary angioplasty, is a technique used to open narrow blood vessels while also placing a stent in the affected blood vessel. CR programs focus on physical fitness along with stress training. Programs offer different aspects depending on the facility. Some may focus more on physical fitness while others incorporate psychological well-being and behavioral changes but they are all aimed at improving overall cardiac health. Due to cardiac rehabilitation, physiological, behavioral, and mood changes may occur. These improvements may include weight, blood pressure, heart rate, depression, body mass index (BMI), walking distance, and walking speed. Mood Research suggests that patients benefit from cardiac rehabilitation programs, specifically in mood. For example, a study of patients with coronary artery disease demonstrated changes in psychological measures including depression and anxiety following rehabilitation (Casey et al., 2009). There were decreases in depression and anxiety from pre- to post-13-week cardiac rehabilitation program. Sharif, Shoul, Janati, Kojuri, and Zare (2012) conducted a study with 80 individuals examining the

7 6 effects of cardiac rehabilitation on anxiety and depression. The participants had undergone CABG surgery prior to enrollment. Two groups were included: intervention and control. The intervention group received four weeks of treatment consisting of training on medication, weight control, stress management, quitting smoking, light exercise, and relaxation. The control group received the typical postoperative care: a cardiac rehabilitation pamphlet about appropriate physical activity, and use of medication. Depression and anxiety measures were taken at three time points. Time one was taken on discharge from the hospital, time two was immediately after the intervention, and time three, two months after CR. After rehabilitation, there was a decrease in depression scores between groups at time one (discharge from hospital), two (immediately after intervention), and three (two months after rehabilitation). There was no difference in anxiety scores between groups. Both groups had reduced anxiety but there was not a statistical difference between groups. This study demonstrates that cardiac rehabilitation training (including exercise, smoking, and weight control) can benefit patients in respect to depressive symptoms; there was no benefit found in anxiety symptoms. Fitness Prior research has demonstrated that throughout cardiac rehabilitation and post rehabilitation, patients fitness improves. These improvements may be seen in greater walking speed and distance. A study by Asbury et al. (2012) demonstrated effects of cardiac rehabilitation on individuals with refractory angina. The cardiac rehabilitation group showed greater improvements in walking speed and distance than the control

8 7 group at the end of the cardiac rehabilitation program. In another study, Grace and colleagues (2008) studied psychosocial and behavioral changes in women who chose to participate in and complete cardiac rehabilitation programs and those who did not participate. Participants included those who had been diagnosed with acute coronary syndrome, percutaneous coronary interventions, or acute coronary bypass. Exercise behavior, anxiety and depressive symptoms were assessed in this study. For those who participated in a rehabilitation program, 18-month post discharge information showed significant improvements in anxiety compared to pre-rehabilitation. For those women who did not participate in the program, there was a significant improvement in physical quality of life and depressive symptoms but not exercise behavior. For those women who did not participate in the program, there was a significant improvement in depressive symptoms. Therefore, exercise behavior was a differentiating factor between groups. Predictors of Change Along with changes that occur pre and post CR program, it is important to examine predictors of change. One study examined 970 patients who completed a 12- week cardiac rehabilitation program from 1996 to 2006 (Frank, McConnell, Rawson, & Fradkin, 2011). Upon entry, participants completed a health-related quality of life (HRQOL) questionnaire. This questionnaire addresses emotional and physical limitations concerning heart disease. The HRQOL includes items pertaining to physical symptoms, ambulation, and self-care. CR classes consisted of exercise, training on heart disease, medication, intimacy, dietary habits, stress, and home

9 8 activities. Measures taken at entry to the program consisted of height, weight, abdominal circumferences, triceps and abdominal skinfolds, grip strength, flexibility, and caloric expenditure during aerobic training. The HRQOL questionnaire was collected pre and post program. Patients demonstrated significant improvements in HRQOL pre- to post-cr. The strongest predictor of changes in the HRQOL was the baseline HRQOL score (Frank, McConnell, Rawson, & Fradkin, 2011). As the baseline HRQOL increased, the magnitude of change in HRQOL decreased. Those with the poorest exercise capacities at entrance tended to make the largest gains in quality of life. Two independent predictors of changes in HRQOL were flexibility and ejection fraction, which is a measure of the percentage of blood exiting the heart when it contracts. In other words, patients with better flexibility and ejection fraction had better HRQOL scores by the end of the program. The authors suggested that those with greater physical functionality may more readily adapt to cardiac rehabilitation and progress more rapidly. Another study examined initial depression and anxiety as possible predictors of physical health decline in patients with heart failure (Shen et al., 2011). Of the 238 patients who participated in this study, approximately half presented with moderate to severe depression and anxiety symptoms. This study demonstrated that increased levels of depression and anxiety at baseline independently predicted physical health functioning and its decline over a 6-month period. Demographics and medical covariates were controlled. Also, an increase in depression and anxiety over 6 months predicted the deterioration of physical functioning. This deterioration could not be

10 9 explained by the baseline levels of depression and anxiety. Furthermore, depression and anxiety symptoms seemed to be highly correlated but they did not correspond completely. Depression and anxiety should be evaluated separately to best help those with heart failure. We are interested in what predicts post cardiac rehabilitation outcomes, and this study shows that physical quality of life was essential. Studies have shown that there are possible predictors of changes in mood post cardiac event such as gender and baseline depressive symptoms. One study examined patients who attended a cardiology outpatient clinic and received an implantable cardioverter defibrillator (ICD). ICDs are used to treat life-threatening arrhythmias that can cause sudden cardiac arrest (von Kanel, Baumert, Kolb, Cho, & Ladwig, 2010). ICD patients demonstrate psychosocial adjustment difficulties and fears, including anxiety and depressive symptoms (von Kanel et al., 2010). The implants needed to be inserted for a period of at least three months and the total patient sample size was 107. To measure posttraumatic stress, the Impact Event Scale-Revised (IES- R) was used. Helplessness and depression measures were also included in this study. Depression was measured with the Hospital Anxiety and Depression Scale (HADS-D). Female gender, helplessness, and depressive symptoms significantly predicted PTSD (post-traumatic stress disorder) at baseline. Female gender and depressive symptoms independently predicted post-traumatic stress at baseline. At follow-up, greater levels of helplessness and baseline post-traumatic stress were all independent predictors of post-traumatic stress. The current study further looks at predictors of changes (e.g., heart history, blood pressure, heart rate) in mood pre- and post-program.

11 10 Heart History Heart history includes all forms of cardiac events that happened in a patient s life. This can include hypertension, stents, myocardial infarctions, etc. One study examined the differences between patients who experienced large myocardial infarctions and less extensive infarctions (Sakuragi, 2013). There were two groups in this study: group 1 contained those with large infarctions (i.e., more severe heart history) and group 2 consisted of members with less extensive infarctions (i.e., less severe heart history). This was determined by peak serum levels of creatine phosphokinase (CPK) immediately after admission to the hospital. These levels indicate left ventricular dysfunction. Those in group 1 had greater dysfunction than those in group 2. A total of 296 patients participated: 64 patients in group 1 and 232 in group 2. Approximately 2 weeks after the onset of the acute myocardial infarction, patients attended cardiac rehabilitation that included only exercise training. This training consisted of 20 minutes on a bicycle and 30 minutes walking or aerobic dance 3 to 5 times per week for 3 months. Compared to patients in group 2 (less severe heart history), those with larger infarction had lower baseline exercise ability before exercise training. After exercise training, group 1 experienced a greater improvement in exercise capacity. Those patients with a larger infarction gained a greater improvement in exercise capacity as compared to those in group 2. Post exercise training, all exercise areas (bicycling, walking, aerobics) became equal between group 1 and 2. These results indicate that patients with more severe history can make greater improvements than those with less severe history.

12 11 Another study examined cardiac events as predictors of lifestyle. This study was a multicenter, prospective, longitudinal study examining predictors of treatment and lifestyle. It consisted of 62 cardiac rehabilitation centers including inpatient and outpatient settings and 1262 total patients. Components of the programs included aerobic activity, diet counseling for weight, and psychosocial management. The patients experienced CABG and/or PCI. This study focused on lifestyle, risk factors, and medication and their relationship with cardiac rehabilitation (Griffo, 2013). This study found that PCI was predictive of sedentary lifestyle and sedentary lifestyle was predictive of reduced treatment adherence. Therefore, it has been demonstrated that not all cardiac events predict the same outcomes after CR. Specific Aims It has been shown that depressive symptoms and exercise significantly improve after CR programs. It has also been shown that there are several predictors of change including increases in depression and anxiety, gender, and helplessness. A predictor of lifestyle was PCI. Although some work has been done examining predictors of change in terms of heart history, the present study aims to further observe total heart history and individual types of events as predictors of CR outcomes. Given the findings reviewed, the primary hypothesis for this research was that mood would improve over the course of the cardiac rehabilitation. The secondary hypothesis was that physical fitness would improve over the course of the cardiac rehabilitation. The following research question was also tested: Are changes in mood

13 12 and fitness influenced by severity of heart disease history, and initial mood, and fitness? Method Participants Sixty-nine participants (age 42-87) who underwent cardiac rehabilitation at HeartWorks in Athens, Ohio, were included in the study. All participants had undergone some cardiac event (e.g. stents, myocardial infarctions). Participants needed to have completed a minimum of 30 of the 36 sessions (83% completion) to be included in the study to ensure full benefits from the program. Procedure Data collected was examined via chart review of former patients at HeartWorks. HeartWorks provided medical records dating from 2005 to 2011 for those who have completed cardiac rehabilitation. The CR program consisted of 36 sessions for duration of 12 weeks. Sessions were held on Monday, Wednesday, and Friday. At least one day per week was devoted to education for stress management and/or relaxation training. Each session lasted approximately 30 minutes. The other days were devoted to exercise. Non-identifying information from medical records was extracted by the investigator via a coding sheet. This data was recorded onto a computer and analyzed thereafter. General information includes age, sex, ethnicity, marital status, date of enrollment, and adherence to program. This study was approved by the Ohio University Institutional Review Board.

14 13 Measures Mood and General Health. Measures of mood included the Beck Depression Inventory (BDI) and the short form-36 (SF-36). These measures were collected pre and post cardiac rehabilitation. The BDI is a 21 question self-report questionnaire which measures the presence and severity of depressive symptoms (Beck et al., 1961). High scores indicate more depressive symptoms. Scores ranging from zero to ten show normal ups and downs. Scores from 11 to 16 demonstrate mild mood disturbances, and scores between 17 and 20 indicate borderline clinical depression. Scores ranging from show moderate depression and scores between 31 and 40 indicate severe depression. Any scores over 40 demonstrate extreme depression. An example question is: Sadness, 0 I do not feel sad, 1 I feel sad much of the time, 2 I am sad all the time, or 3 I am so sad or unhappy that I can t stand it. Means, standard deviations, and alphas are listed the results section in the Mood Changes section. One study suggests that validity of the BDI with respect to other measures of depression is high. The BDI has been shown to have strong positive relationships with four wellstudied instruments assessing depression: Hamilton Psychiatric Rating Scale for Depression (HRSD), the Zung, Minnesota Multiphasic Personality Inventory Depression Scale (MMPI-D), Multiple Affect Adjective Checklist Depression Scale (MAACL-D) (Beck, Steer, & Garbin, 1988). The SF-36 is a self-report questionnaire consisting of 39 questions that measures health excellence (Ware, 1994). This questionnaire has 8 scales including physical functioning, role-physical, bodily pain, general health, vitality, social

15 14 functioning, role-emotional, and mental health. Questions on the physical functioning scale measure moderate activity. The role-physical scale addresses questions about difficulty in tasks (e.g., accomplishing less). Bodily pain questions pertain to pain magnitude and interference with daily living. The vitality scale looks at energy while the social functioning scale measures extent of social activities. Role-emotional measures problems with daily activities due to emotional struggles. The mental health scale measures nervousness, peacefulness, and happiness. Altogether, physical functioning, role-physical, bodily pain, and general health make up the physical health summary. Vitality, social functioning, and role-emotional comprise the mental health summary. Higher scores indicate better functional health whereas low scores demonstrate low functioning and well-being. The average score indicating health is 50. An example question is: In general, would you say your health is: excellent, very good, good, fair, or poor. Data for all eight scales were collected. Studies have shown the SF-36 to have a Cronbach s α greater than.85 and the reliability coefficients were greater than.75 for all dimensions except social functioning (α= 0.73, reliability= 0.74) (Brazier et al., 1992). Fitness. Fitness was measured with a shuttle walk test. Participants were asked to walk as far as they could and as fast they were able for six minutes. The distance and speed (in mph) were recorded pre and post cardiac rehabilitation. During the shuttle walk, predicted VO 2 and METS (metabolic equivalents) were also recorded. VO 2 is a measurement of oxygen consumption that measures the volume of oxygen used by the body to convert dietary energy into energy for the body s usage. METS is

16 15 the amount of oxygen consumed by the body during a certain activity. One MET is the amount of oxygen used while the body is sitting at rest. A MET is equal to 3.5 ml O 2 per kilogram of body weight multiplied by minutes sitting. The DASI (Duke Activity Status Index) was also collected pre and post program (Hlatky, 1989). The DASI is a 12-item self-reported questionnaire regarding physical work capacity. Greater scores indicate better heart health and metabolic equivalents. The maximum score is 58.2 while the lowest score is 0. An example question is Are you able to walk indoors, such as around the house? See the results sections for means, standard deviations, and alphas. The Spearman correlation of the peak oxygen uptake with the DASI was high (0.81, p < ). Peak oxygen uptake was significantly correlated with The Canadian Cardiovascular Society Classification (0.58, p < ) and the Specific Activity Scale (0.67, p < ) (Hlatky, 1989). Heart rate and blood pressure were recorded pre and post CR. Heart rate refers to the number of heart beats per minute. Systolic blood pressure is the amount of pressure on the artery wall when the heart contracts. Diastolic blood pressure is the amount of pressure on artery wall between contractions. Body Composition. Body mass index (BMI), waist circumference, and weight were used to assess body changes. The formula for BMI is: weight (lb) / height (in) 2 x 703. Each was measured at the beginning and end of the program. Cardiac History. Cardiac history was obtained by accessing self-reported medical history. This information was collected by a registered nurse prior to CR. Information was collected regarding stents, bypass grafts, myocardial infarctions,

17 16 angina, hypertension, and any other cardiac incidents or surgeries in the patients lifetimes. The presence or absence of angina was noted along with the number of MI, stents, and CABGs. This information was used to determine the severity of each patient s cardiac health history. A point system was created to measure heart history. One point was given for each CABG, MI, and stent, and one point if angina was present. This scale did not allow for different events to be more or less severe than the others. The highest score was 9 while the lowest was 0. Means and standard deviations are listed in Table 1. Statistical Analysis Physiological and mood changes pre and post rehabilitation were of concern in this study as well as predictors of outcomes such as heart history, baseline mood, and exercise. To test the hypothesis that depressive symptoms improve pre- to post-cr, BDI scores were compared at pre-rehabilitation and post-rehabilitation with paired-t tests. SF-36 and BDI scores were compared at pre-rehabilitation and postrehabilitation with paired-t tests. BMI, heart rate, exercise ability (shuttle walk, DASI, predicted VO 2, METS) were also compared at pre-rehabilitation and postrehabilitation. To examine our research question, severity of patient s cardiac history was analyzed by comparing heart history events. Regression was used to test if severity predicts outcomes. Physical and psychosocial outcome variables include post heart rate, blood pressure, weight, VO 2, METs, SF-36, BDI, etc. Baseline mood and fitness were examined by regression to determine if they predict different outcomes as well.

18 17 Heart history was also examined as a composite score. In addition, individual heart history item were examined separately as predictors of CR outcomes. Specifically, number of stents, MIs, CABGs, and presence of angina were analyzed separately to see if these variables predicted variables pre and post CR. These analyses were run using linear regression. Results Baseline Characteristics Demographics and baseline information are shown in Table 1. At the start of CR, only 8 (11.6%) participants reported having angina. The average weight among the 69 participants was 197 lbs (SD = 40; range: lbs). The average BMI score at intake was (SD = 7.49; range: 21-56), which indicates that the average participant was obese. For waist circumference, the average was inches (SD = 5.13; range: inches). Table 1. Demographics and medical characteristics at start of CR Entry data Total N = 69 (SD / %) Range Men 40 (58%) Age (years) (10.33) Heart Rate (11.58) Systolic Blood Pressure (18.79) Diastolic Blood Pressure (10.06) Angina (present) 8 (11.60%) Stents 1.15 (1.54) 0-6

19 Coronary Artery Bypass Grafts Myocardial Infarctions (49.30%) 29 (41.90%) 5 (7.20%) 1.23 (1.75) 41 (59.40%) 26 (37.6%) 2(2.8%) 0.43 (.60) 43(62.3%) 22(31.9%) 4(5.8%) Total Heart History 2.96(2.26) (55%) (31.8%) 6-9 8(11.4%) Mood and General Health Changes Mood variables were examined by using paired t-tests to examine if they significantly changed before and after CR, as predicted. Results showed that BDI scores significantly decreased from before CR (M = 7.97, SD = 7.12) to after CR (M = 4.68, SD = 6.10), t(64)=6.20, p <.01. This indicates that participants, on average, had improvements in depressed mood. Table 2 describes the paired t-test results for the

20 19 SF-36. As expected from the hypothesis, six out of eight subscales of the SF-36 significantly increased. This indicates that mood significantly improved post CR. Table 2. Baseline and post-cr means, standard deviations, and p values for SF-36 Variable N Baseline At Completion t p Mean (SD) Mean (SD) SF-36 General Health (17.34) (17.93) Physical Functioning (27.42) (27.94) <.001* Role-Physical (41.07) (40.99) <.001* Role-Emotional (37.39) (79.38) Bodily Pain (24.91) (27.57) * Vitality (18.56) (17.56) <.001* Social (24.64) (22.43) * Mental Health (17.23) (15.20) * Note. *p <.05. Physical Changes Paired t-tests were run to examine if weight, BMI, waist circumference, heart rate, METS, predicted VO 2, and DASI significantly changed before and after CR. We hypothesized that all the listed variables would improve after CR. Results show that systolic blood pressure before rehabilitation (M = , SD = 18.79) was significantly higher than systolic blood pressure after CR (M = , SD = 14.45), t(68) = 5.01, p <.01. Diastolic blood pressure also decreased significantly from

21 20 before CR (M = 69.39, SD = 10.06) to after CR (M = 64.32, SD = 8.60), t(68) = 4.23, p <.01. Table 3 demonstrates changes in other physical variables. We expected all variables to significantly improve from pre-program to post-program but BMI and heart rate did not. Although BMI did not decline, there was a slight decline in weight and waist circumference. Changes in other variables (VO 2, METS, DASI) indicate an overall improvement in fitness pre- to post-cr. Table 3. Baseline and post-treatment means, standard deviations, and effect sizes for physical measurement Variable N Baseline At Completion t p Mean (SD) Mean (SD) Weight (40.33) (37.63) * BMI (7.69) (7.37) Waist Circumference (5.37) (4.78) * Heart Rate (11.58) (14.01) METS (.44) 3.23 (.49) <.001* Predicted VO (1.5) (1.79) <.001* DASI (13.04) (16.51) <.001* Average Speed(mph) (.57) 2.90 (.66) <.001* Distance Covered (feet) (302.25) (343.13) <.001* Note. *p<.05; BMI = Body Mass Index; METS = Metabolic Equivalents; DASI = Duke Activity Status Index. Predictors of Change

22 21 Heart History: Composite Score of Severity. Severity of patient s cardiac history was analyzed using linear regression to examine if heart history predicted physiological and psychological changes. Regression analyses were run separately for all physical and mood variables which included BDI, SF-36, blood pressure, weight, BMI, heart rate, waist circumference, METS, predicted VO 2, and DASI. Total heart history did not significantly predict any measures at the start or end of CR, ts < 1.87, ps >.06. Heart History: Individual Predictors. Along with total heart history, MIs, stents, and CABGs were examined to see if they independently predicted change in physical and mood variables. Table 4 demonstrates the significant predictors for separate heart history variables. The number of MIs did not significantly predict any other variables besides BDI after CR and physical-functioning after CR. Number of CABGs did not significantly predict other variables except for role-emotional before CR. The number of stents only significantly predicted mental health and vitality before CR. The research question inquired about cardiac history predicting mood and physical changes. Some cardiac events, when taken separately, do significantly predict some variables, specifically mood variables. Table 4. Linear regression for separate heart severity at pre and post program IV DV Pre or Post R 2 t p B DV MI BDI Post * 2.46 Physical-Functioning Post *

23 22 CABG Role-Emotional Pre * Stents Mental Health Pre * Vitality Pre * Note. *p<.05.; IV = Independent variable; DV = Dependent Variable; MI = Myocardial infarction; CABG = Coronary artery bypass graft. Mood Predictors. BDI and SF-36 variables were used to examine if mood pre CR predicted outcomes post CR. Table 5 demonstrates significant BDI predictors of outcome. Table 6 demonstrates significant SF-36 predictors of outcome. Our research question asked if mood before CR predicted all outcomes so regression was used to examine this question. Table 5. Linear regression for BDI pre program IV DV R 2 t p B BDI DASI BMI General Health Mental Health Physical Functioning Role Physical Social Vitality Waist Circumference Weight

24 23 Table 6. Linear regression for SF-36 variables pre program IV DV R 2 t p B General Health Mental Health Physical Functioning Role Physical Vitality Social BDI DASI Bodily Pain Mental Health Role Physical Vitality BDI DASI General Health Role Physical Social Mental Health BDI < BMI Bodily Pain < Social < Vitality Waist Circumference

25 24 Weight Bodily Pain BDI DASI Heart Rate Mental Health Social < Vitality Weight Role Emotional Feet Covered (Shuttle Walk) Mental Health Role Physical Role Physical Average Speed (Shuttle Walk) BDI DASI < Feet Covered (Shuttle Walk) METS Predicted VO Physical Functioning Vitality Physical Functioning Average Speed (Shuttle Walk) <

26 25 BDI BMI DASI < Feet Covered (Shuttle Walk) < METS < Predicted VO < Mental Health Role Physical < Social Vitality Fitness Predictors. Shuttle walk, predicted VO 2, METS, DASI, heart rate, and blood pressure were used to examine if fitness pre CR predicted outcomes post CR. Table 7 demonstrates significant fitness predictors of outcome. Our research question inquired about fitness before CR predicting all outcomes so regression was used to examine this. Heart rate was not a significant predictor of any variables post CR. Table 7. Linear regression for fitness variables pre program IV DV R 2 t p B Average Speed DASI < (Shuttle Walk) Feet Covered (Shuttle Walk) < METS <

27 26 Predicted VO < Physical Functioning < Role Physical Social Systolic BP Feet Covered (Shuttle Average Speed(Shuttle Walk) < Walk) DASI < METS < Predicted VO < Physical Functioning < Role Physical Social Predicted VO 2 Average Speed(Shuttle Walk) < DASI < Feet Covered(Shuttle Walk) < METS < Physical Functioning < Role Physical Social METS Average Speed(Shuttle Walk) < DASI <

28 27 Feet Covered(Shuttle Walk) < Predicted VO < Physical Functioning < Role Physical Social Systolic BP DASI Average Speed(Shuttle Walk) BDI Feet Covered(Shuttle Walk) < METS < Predicted VO < Physical Functioning Role Physical Systolic BP Role Emotional Diastolic BP Feet Covered(Shuttle Walk) Role Physical Systolic BP Discussion This study examined changes in cardiac rehabilitation data as well as predictors of change. The goal was to study both mood and physical changes and see how they relate by analyzing predictors of change. The hope was to test if heart

29 28 history and initial variables predict ending outcomes. As expected, mood and physical measures improved from pre to post CR. Although total heart history did not predict variables pre or post program, separate heart events did predict mood measures both pre and post CR. Initial mood and fitness predicted both mood and physical outcomes after CR. It has been shown that depressive symptoms are common for patients entering a CR program. Our study looked at changes in depression and other mental health by using the BDI and SF-36. It was demonstrated that depression scores decreased after CR. This is in line with previous research which showed that depressive symptoms decrease after CR (Casey et al., 2009). However, Grace and colleagues research demonstrated (2008) decreases in depressive symptoms among the control group. It is important to note that BDI scores were normal both before and after CR. Scores between zero and ten indicate normal ups and downs. The average BDI score prior to CR was 7.97 while the average score was 4.68 after CR. Not only is this study examining depression, we used the SF-36 to study general health which includes a mental health subscale. There were several mental health improvements shown in the SF-36. These improvements include physical functioning, role-physical, bodily pain, vitality, social and mental health subscales. Since depression and anxiety are often present in patients going through CR, it is promising to see that the HeartWorks program might be playing a role in reducing both depression and other areas of mental health however a control group was not tested so we are not certain if the changes are due to nature or the CR.

30 29 Along with mood changes, we saw several physical changes happen after CR. These include decreased weight, waist circumference, systolic blood pressure, diastolic blood pressure, and increased METS, predicted VO 2, and DASI scores. These variables demonstrate that exercise training, stress management, and relaxation education might be beneficial to patients in CR. One study by Asbury and colleagues (2012) showed improvements in walking speed and distance after CR when compared to a control group. The current study goes beyond walking speed and distance and measures predicted VO 2 and METS during the shuttle walk. Although there were significant changes in both mood and physical measures, total heart severity did not significantly predict any measures. However, when heart severity measures were taken into account separately, several variables were shown to be predicted by MIs, CABGS, and stents. Past research has shown PCI to be predictive of sedentary lifestyle and sedentary lifestyle was predictive of reduced treatment adherence but CABG was not predictive of sedentary lifestyle (Griffo, 2013). The current study goes beyond PCI and CABG and examines MIs, stents, and angina in addition to CABG as predictors of physical and mood outcomes. Heart history, when examined separately, predicted pre and post measures of mood variables. The number of MIs significantly predicted increases in BDI and decreases in SF-36 subscale, physical functioning after CR. If a participant had more MIs, there was an increased chance of them having higher depression scores. Number of CABGs significantly predicted decreases in SF-36 subscale role-emotional before CR. Number of stents significantly predicted decreases in SF-36 subscales, mental health and

31 30 vitality before CR and the presence of angina was not a good predictor of outcomes. As the number of stents went up, the scores of mental health and vitality went down. As expected, all variables prior to program significantly predicted that same variable after CR. Differences in outcomes as a function of heart history may be a due to the method of calculating heart history. Total heart history was a measure we created which added up each stent, CABG, and MI. Each event received one point and one more point if the patient experienced angina. This method does not allow certain events to be seen as more severe than others. The ambiguity of research done on heart severity led to creating a scale where all events were of equal severity. Hypertension was not included due to the several reasons why one might experience hypertension. Hypertension is also a risk factor for many disorders, not only heart disease. BDI and all eight of the SF-36 subscale significantly predicted outcomes. Outcomes include both mood and fitness variables. The most surprising predictions included BDI and the mental health subscale predicting BMI, waist circumference, and weight. This demonstrates that depressive symptoms and mental health preprogram predicted physical changes post CR. Bodily pain pre CR predicted DASI scores and weight post CR. The physical functioning subscale predicted BDI and mental health. This shows that physical activity foresaw mental state post program. Other studies have examined mood and predictors of change. A study showed that an increase in depression over 6 months predicted deterioration of physical functioning (Shen et al., 2011). Another study showed that depressive symptoms predicted post-

32 31 traumatic stress disorder at baseline (von Kanel, Baumert, Kolb, Cho, & Ladwig, 2010). Fitness significantly predict several outcomes including both physical and mood variables. Average speed and distance covered on the Shuttle Walk, predicted VO 2, and METS predicted SF-36 subscales physical functioning, role physical, and social. The DASI pre-program predicted BDI scores post program. Surprisingly, systolic blood pressure predicted role emotional on the SF-36. Other studies have examined physical predictors of change. One of these studies tested health-related quality of life (HRQOL). The greatest predictor of HRQOL was baseline HRQOL (Frank, McConnell, Rawson, & Fradkin, 2011). Other predictors of change in HRQOL were flexibility and ejection fraction. This study demonstrates that physical measures predict outcomes after CR. There are a few limitations to this study. The sample size was relatively small at 69 participants. We also did not have a control group due to two reasons. It is unethical to suggest patients not receive rehabilitation after a severe cardiac event and no data was collected on patients who opted to not complete a CR program. Future studies could include a control group that would be beneficial to demonstrate if patients who do not undergo CR also have decreased depression, mental health scores, weight, waist circumference, and blood pressure and increased fitness measures. It would also be beneficial to compare the control and experimental group in terms of initial measures. This would generalize the initial data for patients who choose to attend CR and help us encourage the others to attend CR.

33 32 Despite these limitations, there are also some notable strengths which include a wide variety of variables. Mood was measured with the BDI and the SF-36. The SF- 36 includes eight subscales that help us examine measures such as social skills, vitality, and mental health. We also measured several physical measures, which include blood pressure, shuttle walk, weight, waist circumference, and heart rate. While other studies have examined only a couple heart events, the current study examined MIs, CABG, stents, and angina as predictors of physical and mood outcomes and we studies total heart history. In conclusion, this 12-week CR program has shown to be effective in a sample of 69 patients who had experienced at least one cardiac event (e.g., MI, stents, angina, CABG). Improvements were seen in both mood and physical changes. Depressive symptoms decreased and general health scores increased. Weight, waist circumference, blood pressure, predicted VO 2, METS, and Shuttle Walk all improved after the CR program. Although total heart history did not predict any measures, individual events did predict both fitness and mood measures. When fitness and mood variables were taken as predictors, they showed to foresee several other variables of mood and fitness type. These findings merit further studies designed to examine more specific mood, fitness, and heart history predictors. A controlled study would aid in the explanation of changes from before to after CR.

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