Commentary on Yohannes AM, Doherty P, Bundy C & Yalfani A (2010) The long‐term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life. Journal of Clinical Nursing 19, 2806–2813

Cardiac rehabilitation services are comprehensive programmes involving education, exercise, counselling and behaviour modification designed to reduce adverse physiological and psychosocial outcomes of heart disease, risk of incident recurrence and mortality. As such, the goal of cardiac rehabilitation programs is not only to prolong life but also to improve physical functioning, symptoms, well-being and health-related quality of life (HRQoL). However, despite a 50-year history and extensive evidence, including systematic reviews (Dinnes et al. 1999, Clark et al. 2005a, Papadakis et al. 2005, Neubeck et al. 2009) and meta-analyses (Oldridge et al. 1988, O’Connor et al. 1989, Jolliffe et al. 2001, Taylor et al. 2004, Clark et al. 2005b, Dalal et al. 2010) attesting to its clinical and cost-effectiveness, very little is known about the long-term benefits of cardiac rehabilitation, with psychosocial outcomes reported least of all. Yohannes et al. (2010) endeavoured to address this gap by reporting the findings of a six-week comprehensive cardiac rehabilitation programme structured on the recommendations of the National Service Framework for Coronary Heart Disease (Department of Health 2000) regarding physical activity, psychological status and HRQoL in patients with coronary heart disease. The study resulted in positive outcomes across all variables over a 12-month period. Interestingly, the correlation between depression and HRQoL as measured by the MacNew instrument (Höfer et al. 2004) explained 79% of the variance at 12 months, yet the correlation between depression and total energy expenditure only explained 5% of the variance. The benefits gained from the six-week rehabilitation programme in this study could not be explained by significant changes in physical activity contrary to previous research that has identified many multi-risk factor benefits of cardiac rehabilitation as a direct result of regular physical activity and exercise training (Benzer et al. 2003, 2006, Wisloff et al. 2007). Although the findings presented by Yohannes et al. (2010) were significant at all time points (six weeks, six months and 12 months) and across all variables – depression, anxiety, HRQoL and energy expenditure – two important limitations acknowledged by the authors should be noted. First, the lack of a control group substantially impedes attributing the improved outcome measures to the six-week cardiac rehabilitation programme alone. Moreover, as there is negligible documentation on the long-term psychosocial outcomes of cardiac rehabilitation, this highlights the problematic nature of identifying the effect of cardiac rehabilitation from other factors. Second, although the authors attested to the gender differences, e.g. in energy expenditure, the sample size of 105 patients at six and 12 months was inadequate for subgroup analyses. In addition, recent findings from a similar study (Höfer et al. 2010) investigating long-term outcomes from an comprehensive four-week cardiac rehabilitation programme (n = 351 at two years) found a significant short-term improvement in HRQoL (at one month), yet at two years follow-up, HRQoL significantly decreased in all of the MacNew scales. While Yohannes et al. (2010) presented a study of clinical relevance, their findings offer little new information and their recommendation that cardiac rehabilitation programmes should be comprehensive and involve psychological strategies rehearses much that is well accepted in the associated literature and recommended in most contemporary clinical practice guidelines.