| Background and objective:Cardiac Rehabilitation(CR)could comprehensively optimize the physical,psychological,and social conditions of patients with coronary heart disease(CHD).Also,CR helps to stabilize,slow,or even reverse the underlying atherosclerotic process,ultimately effectively reducing recurrent myocardial infarction and cardiac death in patients with acute myocardial infarction(AMI).People have realized that high perceived stress may play a role in the development and progression of CHD and the importance of stress management in CR.However,data on the perceived stress levels of the CHD population in China is still lacing.The relationship between high perceived stress and the prognosis in CHD patients also remains unknown.Relevant research has mainly focused on outpatient rehabilitation and there is no unified consensus about early stress management and exercise training strategies on inpatient rehabilitation(phrase I CR).The objective of the study is to investigate the perceived stress of patients with CHD and determine the individual attributes closely associated with it;to compare the effects of the different perceived stress levels on the risk of clinical events and to explore a practical comprehensive phrase I CR program integrating stress management and exercise training in AMI patients.Methods:Part 1: A cross-sectional analysis enrolling 2215 CHD patients was used.Perceived stress was assessed with the Chinese version Perceived Stress Scale(CPSS)and patients’ sociodemographic information,living habits,and clinical information were also collected.Categorical regression was applied to analyze the factors that may affect perceived stress level.Part 2: A prospective observational cohort study enrolling 2215 CHD patients was used.All the subjects were divided into a high-perceived stress group(CPSS≥31 points,523 patients)and a non-high-perceived stress group(CPSS<31 points,1692 patients).Follow-up continued until the date of an endpoint(re-hospitalization for cardiovascular causes)or until March 31,2022,whichever occurred first.The Kaplan-Meier method was used to draw the survival curve,and a log-rank test was used to compare the differences between the two groups.Additionally,landmark analysis was applied to assess outcomes at 24 months and after adjustment for sociodemographic factors,living habits,and clinical information.Part 3: A randomized controlled clinical trial including 102 AMI patients in the cardiac care unit was used.All the subjects were randomly allocated into 3 groups and given different phase I CR programs.The conventional group(33 patients)only received routine therapy,the exercise group(35 patients)was given an early exercise training program including limb exercise,cycle ergometer,and respiratory training within 24-48 hours after admission while the comprehensive group(34 patients)was given enhanced stress management measures including education,relaxation,and support and an early exercise training program.CPSS and impedance cardiograph were performed at the time of admission,discharge,and 6 months after discharge while a six-minutes walking test(6MWT)was performed at discharge and 6 months after discharge.Follow-up also continued until 6 months after discharge and any clinical events(unscheduled revascularization,re-infarction stroke,and death)that occurred during the study period were recorded.The psychological and physiological effects and the safety of different phase I CR programs were compared.Results:Part 1: The mean CPSS score of CHD patients was 27.2 ± 6.4 points.Also,female,higher educated,engaging in mental labor,and having a habit of risky alcohol consumption were associated with relative higher perceived stress(P = 0.035,<0.001,<0.001,0.004);the sum importance of the four factors to CPSS is 53.3%.Part 2: During a median follow-up of 47 months,there were 98 cases of re-hospitalization for cardiovascular causes in the high-perceived stress group while 239 cases in the non-highperceived stress group.Log-rank analysis suggested that the high perceived stress group had a higher rate of re-hospitalization than the non-high perceived stress group(P =0.012).After adjustment for socio-demographics,lifestyle habits,and clinical information,high perceived stress still increased the risk of clinical events at 24 months(HR 1.369,95%CI 1.037-1.807,P =0.027).Part 3: The mean CPSS score of inpatient AMI patients was 29.2±5.2 points which was higher than that of CHD patients outpatient.Patients randomized to the exercise group and comprehensive group exhibited a reduction in perceived stress levels at discharge(-4.0±4.6 and-6.6± 7.1)respectively,and the effect continue to 6 months after discharge.The systemic vascular resistance(SVR)of the exercise group and the comprehensive group was improved compared with the conventional group(P = 0.030);and the left ventricular ejection fraction(LVEF),myocardial contractility index(CTI),and SVR showed greater improvement of the 2intervention groups than the conventional treatment group 6 months after discharge(P = 0.014,0.013,<0.001).The mean distance of the 6MWT at discharge of the exercise group and the comprehensive group were 423.7 ± 62.4 m and 432.1 ± 63.4 m respectively,which were both higher than that of the conventional group(337.6 ± 70.9,P <0.001,<0.001).The rate of clinical events in 6 months was similar among the 3 groups(P = 0.723).Conclusion:The mean CPSS score of CHD patients was 27.2 ± 6.4.Female,higher educated,engaging in mental labor,and having a habit of risky alcohol consumption was associated with relative higher perceived stress with a sum importance of53.3%.CHD patients with high perceived stress(CPSS ≥ 31 points)have a higher risk of clinical events within 24 months than individuals without high perceived stress(HR 1.369,95%CI1.037-1.807).The phase I exercise program and the comprehensive program can effectively reduce the perceived stress of AMI patients during hospitalization and the effect lasts for at least 6 months,and the reduction in CPSS of the comprehensive group is greater.The hemodynamic index measured by impedance cardiograph and exercise capacity were improved in the phase I exercise group and comprehensive group compared with the conventional group while the risk of clinical events within 6 months was not increased. |
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