Editorial: Sudden cardiovascular events and comprehensive cardiac rehabilitation: Come back from “a bolt out of the blue”

Abstract

Cardiovascular events, such as acute myocardial infarction (MI), aortic dissection, and life-threatening ventricular arrhythmia, often develop suddenly. Two-thirds of the patients with first ST segment elevation MI had no prodromal chest pain [1Maruhashi T. Ishihara M. Inoue I. Kawagoe T. Shimatani Y. Kurisu S. Nakama Y. Kagawa E. Dai K. Matsushita J. Ikenaga H. Effect of prodromal angina pectoris on the infarct progression in patients with first ST-elevation acute myocardial infarction.Circ J. 2010; 74: 1651-1657Crossref PubMed Scopus (14) Google Scholar]. These sudden events that are like “a bolt out of the blue” for these patients may be associated with the risk of psychiatric comorbidity. Anxiety is common in patients with cardiovascular diseases. It was reported that the prevalence of anxiety is 70–80% even in patients with acute MI [2Moser D.K. “The rust of life”: impact of anxiety on cardiac patients.Am J Crit Care. 2007; 16: 361-369PubMed Google Scholar]. In addition, depression is three times more common in patients after acute MI than in the general community [3Lichtman J.H. Bigger Jr., J.T. Blumenthal J.A. Frasure-Smith N. Kaufmann P.G. Lespérance F. Mark D.B. Sheps D.S. Taylor C.B. Froelicher E.S. American Heart Association Prevention Committee of the Council on Cardiovascular Nursing American Heart Association Council on Clinical Cardiology American Heart Association Council on Epidemiology and Prevention American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research American Psychiatric Association Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association.Circulation. 2008; 118: 1768-1775Crossref PubMed Scopus (1080) Google Scholar, 4Hare D.L. Toukhsati S.R. Johansson P. Jaarsma T. Depression and cardiovascular disease: a clinical review.Eur Heart J. 2014; 35: 1365-1372Crossref PubMed Scopus (644) Google Scholar]. It was also reported that the prevalence of major depression is 15–20% in patients with acute MI and an even greater proportion show an elevated level of depressive symptoms [3Lichtman J.H. Bigger Jr., J.T. Blumenthal J.A. Frasure-Smith N. Kaufmann P.G. Lespérance F. Mark D.B. Sheps D.S. Taylor C.B. Froelicher E.S. American Heart Association Prevention Committee of the Council on Cardiovascular Nursing American Heart Association Council on Clinical Cardiology American Heart Association Council on Epidemiology and Prevention American Heart Association Interdisciplinary Council on Quality of Care and Outcomes Research American Psychiatric Association Depression and coronary heart disease: recommendations for screening, referral, and treatment: a science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Psychiatric Association.Circulation. 2008; 118: 1768-1775Crossref PubMed Scopus (1080) Google Scholar]. Myocarditis is an inflammatory disease of the myocardium that results in ventricular systolic dysfunction and may account for up to 10% of acute-onset heart failure [5Gupta S. Markham D.W. Drazner M.H. Mammen P.P. Fulminant myocarditis.Nat Clin Pract Cardiovasc Med. 2008; 5: 693-706Crossref PubMed Scopus (146) Google Scholar]. Fulminant myocarditis is characterized by uncommon features in clinical and histopathological findings distinct from the features of nonfulminant myocarditis. The patients with fulminant myocarditis present with an acute onset of severe heart failure, often in previously healthy individuals. Patients with fulminant myocarditis should be managed with aggressive inotropic support such as an intra-aortic balloon pump, and mechanical circulatory support at the early phase when needed. If fulminant myocarditis is quickly diagnosed and treated using aggressive strategies, more than 90% of the patients will make a full recovery with minimal long-term sequelae [5Gupta S. Markham D.W. Drazner M.H. Mammen P.P. Fulminant myocarditis.Nat Clin Pract Cardiovasc Med. 2008; 5: 693-706Crossref PubMed Scopus (146) Google Scholar, 6McCarthy 3rd, R.E. Boehmer J.P. Hruban R.H. Hutchins G.M. Kasper E.K. Hare J.M. Baughman K.L. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis.N Engl J Med. 2000; 342: 690-695Crossref PubMed Scopus (665) Google Scholar]. However, even after ventricular recovery, adequate medications of heart failure should be administered, and psychiatric support may also be needed because the prevalence of anxiety and depression were reported to be 38% and 27%, respectively, in fulminant myocarditis patients who were rescued by mechanical circulatory support [7Mirabel M. Luyt C.E. Leprince P. Trouillet J.L. Léger P. Pavie A. Chastre J. Combes A. Outcomes, long-term quality of life, and psychologic assessment of fulminant myocarditis patients rescued by mechanical circulatory support.Crit Care Med. 2011; 39: 1029-1035Crossref PubMed Scopus (175) Google Scholar]. In this issue of the journal, Sasanuma et al. [8Sasanuma N. Takahashi K. Yamauchi S. Itani Y. Tanaka T. Mabuchi S. Kodama N. Masuyama T. Domen K. A five-year follow-up of a patient with fulminant myocarditis who underwent a stepwise and goal-oriented individualized comprehensive cardiac rehabilitation program.J Cardiol Cases. 2015; 11: 160-163Abstract Full Text Full Text PDF Scopus (3) Google Scholar] have reported a case of fulminant myocarditis, in which the patient underwent a stepwise and goal-oriented individualized comprehensive cardiac rehabilitation program for five years. The cardiac rehabilitation team started intervention on hospital day 3. The patient was allowed to walk indoors with assistance and to get into a wheelchair on hospital day 10. While, his cardiac function had smoothly recovered, his physical function and psychiatric problems, including anxiety and loss of self-confidence, did not sufficiently recover. Therefore, the multidisciplinary team continued physical rehabilitation, exercise therapies, and mental support, not only at the acute phase of onset but also after hospital discharge for five years. The comprehensive and long-term interventions succeeded to recover cardiopulmonary function within the normal range and improved the mental and physical component summaries assessed by the Quality of Life (QOL) scale above the mean levels of age- and gender-matched Japanese general populations. Cardiac rehabilitation significantly improves physical function and cardiac risk factors and reduces morbidity and mortality in patients with cardiovascular diseases [9Swift D.L. Lavie C.J. Johannsen N.M. Arena R. Earnest C.P. O’Keefe J.H. Milani R.V. Blair S.N. Church T.S. Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention.Circ J. 2013; 77: 281-292Crossref PubMed Scopus (239) Google Scholar, 10Seki E. Watanabe Y. Sunayama S. Iwama Y. Shimada K. Kawakami K. Sato M. Sato H. Mokuno H. Daida H. Effects of cardiac rehabilitation programs in chronic phase III on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP).Circ J. 2003; 67: 73-77Crossref PubMed Scopus (66) Google Scholar, 11Onishi T. Shimada K. Sato H. Seki E. Watanabe Y. Sunayama S. Ohmura H. Masaki Y. Nishitani M. Fukao K. Kume A. Sumide T. Mokuno H. Naito H. Kawai S. et al.Effects of phase III cardiac rehabilitation on mortality and cardiovascular events in elderly patients with stable coronary artery disease.Circ J. 2010; 74: 709-714Crossref PubMed Scopus (23) Google Scholar]. It also improves psychological problems, including anxiety, depression, lack of self-confidence, emotional stress, social isolation, and QOL [9Swift D.L. Lavie C.J. Johannsen N.M. Arena R. Earnest C.P. O’Keefe J.H. Milani R.V. Blair S.N. Church T.S. Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention.Circ J. 2013; 77: 281-292Crossref PubMed Scopus (239) Google Scholar, 10Seki E. Watanabe Y. Sunayama S. Iwama Y. Shimada K. Kawakami K. Sato M. Sato H. Mokuno H. Daida H. Effects of cardiac rehabilitation programs in chronic phase III on health-related quality of life in elderly patients with coronary artery disease: Juntendo Cardiac Rehabilitation Program (J-CARP).Circ J. 2003; 67: 73-77Crossref PubMed Scopus (66) Google Scholar]. Furthermore, previous studies reported that cardiac rehabilitation was performed in fulminant myocarditis patients with mechanical device supports [12Sugamura K. Sugiyama S. Kawano H. Horio E. Ono S. Kojima S. Kaikita K. Sagishima K. Sakamoto T. Yoshimura M. Kinoshita Y. Ogawa H. Fulminant myocarditis survivor after 56 hours of non-responsive cardiac arrest successfully returned to normal life by cardiac resynchronization therapy: a case report.J Cardiol. 2006; 48: 345-352PubMed Google Scholar, 13Gon S. Suematsu Y. Morizumi S. Shimizu T. Experience of a patient with an extracorporeal ventricular assist system who participated in a sleepover program.J Artif Organs. 2011; 14: 257-260Crossref PubMed Scopus (3) Google Scholar, 14Jaroszewski D.E. Marranca M.C. Pierce C.N. Wong R.K. Steidley E.D. Scott R.L. Devaleria P.A. Arabia F. Successive circulatory support stages: a triple bridge to recovery from fulminant myocarditis.J Heart Lung Transplant. 2009; 28: 984-986Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar]. Numerous studies have clearly demonstrated that exercise training reduces anxiety and depression, and improves QOL, exercise tolerance, and the risk of cardiovascular events [4Hare D.L. Toukhsati S.R. Johansson P. Jaarsma T. Depression and cardiovascular disease: a clinical review.Eur Heart J. 2014; 35: 1365-1372Crossref PubMed Scopus (644) Google Scholar, 9Swift D.L. Lavie C.J. Johannsen N.M. Arena R. Earnest C.P. O’Keefe J.H. Milani R.V. Blair S.N. Church T.S. Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention.Circ J. 2013; 77: 281-292Crossref PubMed Scopus (239) Google Scholar, 15Schuler G. Adams V. Goto Y. Role of exercise in the prevention of cardiovascular disease: results, mechanisms, and new perspectives.Eur Heart J. 2013; 34: 1790-1799Crossref PubMed Scopus (162) Google Scholar]. In addition, cognitive behavior therapy provided by rehabilitation staff is obviously effective for improving negative perceptions in patients with cardiovascular diseases [4Hare D.L. Toukhsati S.R. Johansson P. Jaarsma T. Depression and cardiovascular disease: a clinical review.Eur Heart J. 2014; 35: 1365-1372Crossref PubMed Scopus (644) Google Scholar]. Patients are taught to modify their thoughts, change maladaptive behaviors, and develop skills for adapting to negative feelings [4Hare D.L. Toukhsati S.R. Johansson P. Jaarsma T. Depression and cardiovascular disease: a clinical review.Eur Heart J. 2014; 35: 1365-1372Crossref PubMed Scopus (644) Google Scholar]. There are several limitations for performing and continuing cardiac rehabilitation in a clinical setting. First, the implementation of cardiac rehabilitation, particularly for the recovery phase in outpatient clinics, is not necessarily sufficient even in Japan. Second, patient compliance to participate in cardiac rehabilitation is also one of the major limitations. It has been reported that compliance with cardiac rehabilitation gradually decreases after discharge, even in patients with heart failure who were enrolled in sophisticated clinical randomized trials [15Schuler G. Adams V. Goto Y. Role of exercise in the prevention of cardiovascular disease: results, mechanisms, and new perspectives.Eur Heart J. 2013; 34: 1790-1799Crossref PubMed Scopus (162) Google Scholar]. Third, a comprehensive cardiac rehabilitation program includes psychological interventions for patients with psychiatric problems. However, a psychiatric specialist such as a clinical psychologist could not necessarily contribute to the cardiac rehabilitation program. In this situation, physical therapists, nurses, and doctors, instead of clinical psychologists, should provide psychiatric support. Indeed, many physical therapists must be involved in “exercise and talking therapies” as reported in this case report [8Sasanuma N. Takahashi K. Yamauchi S. Itani Y. Tanaka T. Mabuchi S. Kodama N. Masuyama T. Domen K. A five-year follow-up of a patient with fulminant myocarditis who underwent a stepwise and goal-oriented individualized comprehensive cardiac rehabilitation program.J Cardiol Cases. 2015; 11: 160-163Abstract Full Text Full Text PDF Scopus (3) Google Scholar]. Therefore, the cardiac rehabilitation staff needs to acquire skills for providing psychiatric support. At present, there is growing evidence that antidepressant medications such as selective serotonin receptor reuptake inhibitors (SSRIs) have improved depression in patients with cardiovascular diseases [4Hare D.L. Toukhsati S.R. Johansson P. Jaarsma T. Depression and cardiovascular disease: a clinical review.Eur Heart J. 2014; 35: 1365-1372Crossref PubMed Scopus (644) Google Scholar]. However, some clinical trials have failed to show the beneficial effects of antidepressant medication for cardiac patients [4Hare D.L. Toukhsati S.R. Johansson P. Jaarsma T. Depression and cardiovascular disease: a clinical review.Eur Heart J. 2014; 35: 1365-1372Crossref PubMed Scopus (644) Google Scholar]. It may be possible that comprehensive cardiac rehabilitation, comprising exercise, talking, and pharmacological therapies, leads to tremendous benefits to patients with cardiac and psychological problems (Fig. 1). Further studies are needed to improve morbidity and mortality in previously healthy individuals with sudden cardiovascular events.