Trends in mental health and behavioural risk factors of patients in exercise-based cardiac rehabilitation over 25 years: a retrospective cohort study

Abstract Background Cardiovascular rehabilitation (CR) is effective for improving health outcomes and quality of life in patients with cardiovascular diseases (CVD). Behavioural risk factors (e.g., physical inactivity, smoking), and mental health disorders are prevalent among CR patients and represent important challenges for long-term disease management. Despite their relevance, changes in these risk factors among CR participants remain underexplored. Objective To examine 25-year trends in mental health and behavioural risk factors among participants of a large CR reference centre. Methods This observational, retrospective cohort study included patients with CVD who enrolled in a CR program at a large cardiovascular health centre in Canada between 2001 and 2025. All data were extracted in anonymized digital batches from three separate databases, systematically cleaned, and harmonized. We included self-reported levels of moderate-to-vigorous physical activity (MVPA), smoking status (active or non-smoker), and mental health scores (Hospital Anxiety and Depression Scale HADS or Generalized Anxiety Disorder 7-item GAD-7 with Patient Health Questionnaire-9 PHQ-9). HADS ≥11 and GAD-7 and PHQ-9 ≥10 indicates moderate/severe anxiety or depression. Participants were grouped into 5-year enrollment intervals. One-way ANOVA, with Bonferroni post-hoc tests, was used to compare changes in these measures over time. Chi-square analyses, with post-hoc tests, were used to compare the proportion of participants above or below guideline cut-offs. Data are presented as medians (interquartile ranges). Results A total of 27,742 patients (mean SD age, 62 12 years; 29.5% women; 60.5% with coronary artery disease) were included. Median MVPA was 150 (260) minutes/week in 2001-2005, declined to 90 (240) minutes/week in 2016-2020, and increased to 180 (230) minutes/week in 2021-2025 (p0.001). In 2021-2025, 27% of participants met the MVPA guidelines (150-299 minutes/week) and 25% exceeded them (≥300 minutes/week). Non-smokers accounted for 92.9-94.2% of participants between 2001-2015, reflecting a stable profile, and decreased slightly in 2016-2020 (89.7%) and 2021-2025 (90.6%) (p0.001). Anxiety scores showed significant differences, with moderate/severe anxiety decreasing from 14% (2001-2015) to 10% (2021-2025) (p0.001), and moderate/severe depression fluctuated from 5.9% (2006-2010), 7.7% (2016-2020), and decreased to 4.6% (2021-2025) (p0.001). Proportion of participants with depression scores within a normal range increased in the past 5 years compared with earlier intervals (p0.001). Conclusion Recent improvements in physical activity and mental health are encouraging, but the slight rise in smoking prevalence warrants attention. These findings underscore the evolving profile of CR participants, highlighting the need for serial monitoring to guide continued integration of physical activity promotion and psychosocial support within CR programming.