Variability in Cardiac Rehabilitation Program outcomes according to baseline emotional status: A Real-World analysis

Abstract Background Psychological distress is frequently observed among patients enrolled in Cardiac Rehabilitation Programs (CRPs) and appears to significantly influence rehabilitation outcomes. However, its impact remains underrecognized and often underestimated in clinical practice. Understanding its influence is key to developing more personalized and effective interventions. Purpose To investigate the association between baseline psychological distress and outcomes in individuals undergoing a multidisciplinary CRP. Methods We conducted a retrospective observational study (Jan 2023–Oct 2025) including patients enrolled in a multidisciplinary CRP. The CRP combined supervised aerobic and resistance training 2x/week for 3-months with structured education sessions on diet and stress management. Psychological intervention was not integrated, reflecting implementation challenges in routine clinical practice. Psychological distress was assessed at baseline using the Hospital Anxiety and Depression Scale (HADS), with scores 7 on each subscale. Participants were grouped accordingly, including a category for emotional comorbidity (both anxiety and depression). Outcomes assessed included body composition, muscle strength, cardiopulmonary fitness, and patient-reported measures. Results 209 patients were assessed; 159 completed the CRP and were included in the analysis. Based on emotional screening at baseline, participants were classified into four groups: no emotional distress (n=88), anxiety (n=27), depression (n=8), and emotional comorbidity (n=36). The comparative analysis of CRP outcomes across these groups is presented in Table 1. The no-distress group showed the most consistent and significant improvements across all outcomes. Improvement in bodu composition were accompanied by gains in muscular strength, cardiorespiratory fitness, dietary adherence, QoL, and physical activity. The anxiety group also improved in several areas like muscular strength, METs, QoL, and physical activity. BMI decreased, and VO2 peak showed a positive trend. The comorbidity group demonstrated meaningful improvements despite emotional burden. Strength, METs, dietary adherence, QoL, and physical activity all increased significantly. The depression group, showed limited response. BMI increased and QoLdeclined. No significant changes were observed in strength, fitness, or lifestyle indicators, and the small sample size may limit interpretation. Conclusions Our study indicates that emotional profiles variably influence CRP outcomes. Anxiety–depression comorbidity, followed by isolated depression, was associated with poorer outcomes across multiple domains, although findings are limited by sample size. Recognizing its influence is essential for developing more personalized interventions and prioritizing psychological care for emotionally vulnerable individuaFor image description, please refer to the figure legend and surrounding text.