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Cochrane Database of Systematic Reviews

Intervensi psikologi untuk penyakit jantung koronari

Information

DOI:
https://doi.org/10.1002/14651858.CD002902.pub4Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 28 April 2017see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Heart Group

Copyright:
  1. Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

  • Suzanne H Richards

    Leeds Institute of Health Sciences, University of Leeds, Leeds, UK

  • Lindsey Anderson

    Institute of Health Research, University of Exeter Medical School, Exeter, UK

  • Caroline E Jenkinson

    Primary Care, University of Exeter Medical School, Exeter, UK

  • Ben Whalley

    School of Psychology/Cognition Institute, Plymouth University, Plymouth, UK

  • Karen Rees

    Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK

  • Philippa Davies

    Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK

  • Paul Bennett

    Department of Psychology, University of Swansea, Swansea, UK

  • Zulian Liu

    Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK

  • Robert West

    Wales Heart Research Institute, Cardiff University, Cardiff, UK

  • David R Thompson

    School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK

  • Rod S Taylor

    Correspondence to: MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, UK

    [email protected]

Contributions of authors

SR: study selection, data extraction, risk of bias assessment and analyses, led the writing of the updated review, and approved the final manuscript.

LA: study selection, data extraction, risk of bias assessment and analyses, and edited and approved the final manuscript.

CJ: study selection, data extraction, risk of bias assessment, and edited and approved the final manuscript.

BW: wrote the previous version of this review, advised with study selection and analyses, provided clinical advice, and edited and approved the final manuscript. BW was the lead author on the second version (2011) of this Cochrane review.

KR: edited and approved the final manuscript. KR was the lead author on the first version (2004) of this Cochrane Review, and a co‐author on the second version (2011).

PD: edited and approved the final manuscript. PD was a co‐author on the second version (2011) of this Cochrane Review.

PB: edited and approved the final manuscript. PB was a co‐author on both the first version (2004) and second version (2011) of this Cochrane Review.

ZL: edited and approved the final manuscript. ZL was a co‐author on the second version (2011) of this Cochrane Review.

RW: edited and approved the final manuscript. RW was a co‐author on both the first version (2004) and second version (2011) of this Cochrane Review.

DRT: edited and approved the final manuscript. DRT was a co‐author on the second version (2011) of this Cochrane Review.

RST: advised on study selection, data extraction, risk of bias assessment, and analyses, and edited and approved the final manuscript. RST was a co‐author on the second version (2011) of this Cochrane Review.

Sources of support

Internal sources

  • Department of Social Medicine, University of Bristol, UK

    Supporting Philippa Davies

  • Cardiff University, UK

    Supporting Robert West

  • University of Exeter Medical School, UK

    Supporting Suzanne Richards, Lindsey Anderson, and Rod Taylor

  • National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust, UK

    Supporting Rod Taylor. The views and opinions expressed therein are those of the review authors and do not necessarily reflect those of National Health Service, the UK NIHR, or the UK Department of Health

  • Academic Unit of Primary Care, Leeds Institute of Health Sciences, University of Leeds, UK

    Supporting Suzanne Richards

External sources

  • British Heart Foundation, UK

  • ESRC, UK

    Postdoctoral Fellowship for Ben Whalley (PTA‐026‐27‐2113)

  • NIHR Health Technology Assessment Programme, UK

    Cadence Study (12/189/06) ‐ part‐support for Suzanne Richards and Rod Taylor
    The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR Health Technology Assessment Programme, NIHR, National Health Service, or the Department of Health, UK.

  • South West General Practice Trust (registered charity 292013), UK

    Small project award to support Caroline Jenkinson and Lindsey Anderson

  • Cochrane Infrastructure funding to the Heart Group, UK

    The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR Systematic Reviews programme, NIHR National Health Service, or UK Department of Health

Declarations of interest

SR is currently a coinvestigator on the CADENCE study (funded by the UK NIHR HTA 12/189/06). This study is a feasibility and pilot study aimed at developing enhanced psychological care for people with new‐onset depression using cardiac rehabilitation services (ISRCTN34701576).

LA is an author on several other Cochrane cardiac rehabilitation reviews.

CJ declares she has no conflicts of interest.

KR, PB, and RW were authors of the first version (2004) of this Cochrane Review.

BW, KR, PD, PB, ZL, RW, DRT, and RST were authors of the second version (2011) of this Cochrane Review.

KR is an author on several other Cochrane cardiac rehabilitation reviews.

RST is an author on several other Cochrane cardiac rehabilitation reviews. RST is currently the co‐chief investigator on the programme of research with the overarching aims of developing and evaluating a home‐based cardiac rehabilitation intervention for people with heart failure and their carers (UK NIHR PGfAR RP‐PG‐0611‐12004). RST is currently a coinvestigator on the CADENCE study (funded by the UK NIHR HTA 12/189/06). This study is a feasibility and pilot study aimed at developing enhanced psychological care for people with new onset depression using cardiac rehabilitation services (ISRCTN34701576).

Acknowledgements

We would like to acknowledge the support of Professor John Campbell (University of Exeter Medical School) and the South West General Practice Trust who provided a small grant to assist with the data preparation for the third update. This work was also supported indirectly through a grant from the UK National Institute of Health Research (NIHR) Health Technology Assessment programme for the 'Cadence Study' (project 12/189/06), which facilitated Suzanne Richards' and Rod Taylor's contribution to this work. Rod Taylor was also supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula at the Royal Devon and Exeter NHS Foundation Trust. (Note, the funding agencies have not been substantively involved in the design, or data acquisition for this research, neither the drafting of this manuscript; the views and opinions expressed in this paper are those of the authors and do not necessarily reflect those of the National Health Service, the UK NIHR funding agencies, or the UK Department of Health.) We would like to acknowledge all authors who provided additional information on request (authors from the following trials: ENRICHD Investigators 2000; Jones 1996; Oldenburg 1985; O'Neil 2015), Cornelia Junghans for the Russian and German translations, Jerong Ji for the Chinese translation, and Mensrain Mujeeb for the Farsi translation. We also thank Linda Long of the Cochrane Heart Group, University of Exeter, for some data checking undertaken during the final stage of the editorial review process. Ben Whalley was supported by an ESRC postdoctoral fellowship during the drafting of the second update (PTA‐026‐27‐2113). We would also like to acknowledge the input of two people who coauthored the previous update (Professor Shah Ebrahim and Tiffany Moxam), but did not contribute to this third update. The authors acknowledge the support of the Cochrane Heart Group editorial team and the template protocol they made available.

Version history

Published

Title

Stage

Authors

Version

2017 Apr 28

Psychological interventions for coronary heart disease

Review

Suzanne H Richards, Lindsey Anderson, Caroline E Jenkinson, Ben Whalley, Karen Rees, Philippa Davies, Paul Bennett, Zulian Liu, Robert West, David R Thompson, Rod S Taylor

https://doi.org/10.1002/14651858.CD002902.pub4

2011 Aug 10

Psychological interventions for coronary heart disease

Review

Ben Whalley, Karen Rees, Philippa Davies, Paul Bennett, Shah Ebrahim, Zulian Liu, Robert West, Tiffany Moxham, David R Thompson, Rod S Taylor

https://doi.org/10.1002/14651858.CD002902.pub3

2004 Apr 19

Psychological interventions for coronary heart disease

Review

Karen Rees, Paul Bennett, Robert West, George Davey Smith, Shah Ebrahim

https://doi.org/10.1002/14651858.CD002902.pub2

2000 Sep 26

Psychological interventions for coronary heart disease

Review

Karen Rees, Paul P Bennett, Robert R West, George Davey Smith, Shah BJ Ebrahim

https://doi.org/10.1002/14651858.CD002902

Differences between protocol and review

This current (third) update relates to a review first published in 2004 and subsequently updated in 2011. The following changes were implemented to this 2016 update, modifying the procedures reported in 2011.

In terms of eligibility criteria, cardiac rehabilitation services are offering care to more varied populations of people with cardiac conditions (e.g. people with heart failure or arrhythmias). Building on the inclusion criteria proposed by Whalley 2011, this third update now includes trials evaluating psychological interventions recruiting cardiac populations where at least 50% or more of the participant population has an acute coronary syndrome or angina. More recent studies are also seeking to test psychological interventions in comorbid populations (i.e. people with depression, and either acute coronary syndrome or diabetes). These studies were deemed eligible for inclusion as long as the outcome data were reported separately and could be extracted for the subgroup of people with heart disease.

Regarding data synthesis, we also report meta‐analysis of the outcome of participant‐reported stress levels, and the findings from studies reporting participants' levels of return to work, or data on economic evaluations conducted alongside trials. The GRADE assessment of the quality of evidence for each of the primary outcomes is also reported. Finally, we have narrowed the scope of the meta‐regression analysis by limiting our investigation to a smaller number of key parameters compared with those explored in the second update.

Notes

All stages of this review update were conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and complied with all "mandatory" requirements of The Methodological Expectations of Cochrane Intervention Reviews (MECIR) (Chandler 2013). Later stages of the update process also met the more rigorous "highly desirable" MECIR standards, reflecting changes in the enforcement of these standards by the Cochrane Heart Group.

Keywords

MeSH

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Flow diagram summarising study selection. N: number of RCT: randomised controlled trial

Figures and Tables -
Figure 1

Flow diagram summarising study selection. N: number of RCT: randomised controlled trial

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Figures and Tables -
Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Figures and Tables -
Figure 3

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for total mortality (Analysis 1.1).

Figures and Tables -
Figure 4

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for total mortality (Analysis 1.1).

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for revascularisation (coronary artery bypass graft surgery and percutaneous coronary intervention combined) (Analysis 1.3).

Figures and Tables -
Figure 5

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for revascularisation (coronary artery bypass graft surgery and percutaneous coronary intervention combined) (Analysis 1.3).

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for non‐fatal myocardial infarction (Analysis 1.4).

Figures and Tables -
Figure 6

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for non‐fatal myocardial infarction (Analysis 1.4).

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for depression (Analysis 1.5).

Figures and Tables -
Figure 7

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for depression (Analysis 1.5).

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for stress (Analysis 1.7).

Figures and Tables -
Figure 8

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for stress (Analysis 1.7).

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for cardiac mortality (Analysis 1.2).

Figures and Tables -
Figure 9

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for cardiac mortality (Analysis 1.2).

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for anxiety (Analysis 1.6).

Figures and Tables -
Figure 10

Funnel plot: psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation) for anxiety (Analysis 1.6).

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 1: Total mortality

Figures and Tables -
Analysis 1.1

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 1: Total mortality

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 2: Cardiac mortality

Figures and Tables -
Analysis 1.2

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 2: Cardiac mortality

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 3: Revascularisation (coronary artery bypass graft surgery and percutaneous coronary intervention combined)

Figures and Tables -
Analysis 1.3

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 3: Revascularisation (coronary artery bypass graft surgery and percutaneous coronary intervention combined)

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 4: Non‐fatal myocardial infarction

Figures and Tables -
Analysis 1.4

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 4: Non‐fatal myocardial infarction

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 5: Depression

Figures and Tables -
Analysis 1.5

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 5: Depression

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 6: Anxiety

Figures and Tables -
Analysis 1.6

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 6: Anxiety

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 7: Stress

Figures and Tables -
Analysis 1.7

Comparison 1: Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation), Outcome 7: Stress

Summary of findings 1. Psychological intervention with or without other rehabilitation compared to control (usual care/other rehabilitation) for coronary heart disease (third update)

Psychological intervention with or without other rehabilitation compared to control (usual care/other rehabilitation) for coronary heart disease (third update)

Patient or population: people with coronary heart disease (third update)

Settings: centre or home based (± telephone support)

Intervention: psychological intervention ± other rehabilitation

Comparison: control (usual care/other rehabilitation)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control (usual care/other rehabilitation)

Psychological intervention +/‐ other rehabilitation

Total mortality
Deaths
Follow‐up: median 13 months

Study population

RR 0.90
(0.77 to 1.05)

7776
(23 studies)

⊕⊕⊕⊝
Moderate1

91 per 1000

82 per 1000
(70 to 95)

Moderate population

36 per 1000

32 per 1000
(28 to 38)

Cardiac mortality
Deaths
Follow‐up: median 57 months

Study population

RR 0.79
(0.63 to 0.98)

4792
(11 studies)

⊕⊕⊝⊝
Low1,2

72 per 1000

57 per 1000
(45 to 71)

Moderate population

49 per 1000

39 per 1000
(31 to 48)

Non‐fatal MI
Follow‐up: median 30 months

Study population

RR 0.82
(0.64 to 1.05)

7845
(13 studies)

⊕⊕⊝⊝
Low1,3

95 per 1000

78 per 1000
(61 to 100)

Moderate population

67 per 1000

55 per 1000
(43 to 70)

Revascularisation (CABG and PCI combined)
Follow‐up: median 12 months

Study population

RR 0.94
(0.81 to 1.11)

6822
(13 studies)

⊕⊕⊕⊝
Moderate1

121 per 1000

114 per 1000
(98 to 135)

Moderate population

115 per 1000

108 per 1000
(93 to 128)

Anxiety
Follow‐up: median 12 months

The mean anxiety in the intervention groups was
0.24 standard deviations lower
(0.38 to 0.09 lower)

3165
(12 studies)

⊕⊕⊝⊝
Low1,2

Depression
Follow‐up: median 12 months

The mean depression in the intervention groups was
0.27 standard deviations lower
(0.39 to 0.15 lower)

5829
(19 studies)

⊕⊕⊝⊝
Low1,4

Stress
Follow‐up: median 12 months

The mean stress in the intervention groups was
0.56 lower
(0.88 to 0.24 lower)

1255
(8 studies)

⊕⊝⊝⊝
Very low1,4,5

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CABG: coronary artery bypass graft; CI: confidence interval; MI: myocardial infarction; PCI: percutaneous coronary intervention; RR: risk ratio.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Random sequence generation, allocation concealment, or blinding of outcome assessors were poorly described in 50% or more of included studies.
2 Egger test suggest evidence of asymmetry and therefore publication bias.
3 The 95% CIs included both no effect and appreciable benefit or harm (i.e. CI < 0.75 or > 1.25).
4 Moderate heterogeneity (I2 > 50%) .
5 95% CIs around the standardised mean difference did not include the value of a +0.5 at either the lower or upper limits, which is an indicator of clinical significance.

Figures and Tables -
Summary of findings 1. Psychological intervention with or without other rehabilitation compared to control (usual care/other rehabilitation) for coronary heart disease (third update)
Table 1. Other psychological outcomes

Trial

Follow‐up (months)

Measure

Scores at follow‐up: intervention vs comparator, P value

Between‐group difference

Depression

Appels 2005

18

Depression (clinical diagnosis, DSM‐IV criteria)

Odds of being depressed, controlling for age, gender, and baseline depression

OR 0.50 (95% CI 0.26 to 0.95), P = 0.04

Intervention > comparator

Freedland 2009

9

Beck Depression Inventory

Mean (SD): CBT 6.7 (8.32); SSM 9.9 (9.07) vs 12.9 (9.29), P < 0.001

Intervention > comparator

Mayou 2002

12

Hamilton Anxiety and Depression Combined Score

Median (IQR): 6 (2 to 9) vs 7 (4 to 11.5); mean difference ‐2.35 (SD NR), P = NS

Intervention ≈ comparator

O'Neil 2015

6

Patient Health Questionnaire ‐ 9

Mean (SD): 6.1 (5.5) vs 8.1 (5.8), P = NS

Intervention ≈ comparator

Oranta 2010

18

Beck Depression Inventory (diagnosis)

OR 0.31 (95% CI 0.16 to 0.61) vs 1.15 (95% CI 0.60 to 0.22), P = 0.009

Intervention > comparator

Distress

Oranta 2010

18

Symptom Checklist‐25

OR 0.4 (95% CI 0.21 to 0.84) vs 0.9 (95% CI 0.43 to 1.86), P = NS

Intervention ≈ comparator

Anger

Michalsen 2005

12

Anger (STAXI): State

Mean (SD): 10.9 (2.3) vs 11.1 (2.6), P = NS

Intervention ≈ comparator

12

Anger (STAXI): Trait

Mean (SD): 17.4 (4.2) vs 18 (4.8), P = NS

Intervention ≈ comparator

12

Anger (STAXI): In

Mean (SD): 17.1 (4.7) vs 16.8 (4.9), P = NS

Intervention ≈ comparator

12

Anger (STAXI): Out

Mean (SD): 11.6 (2.7) vs 11.5 (3.1), P = NS

Intervention ≈ comparator

12

Anger (STAXI): Control

Mean (SD): 24.5 (4.2) vs 24.4 (4.5), P = NS

Intervention ≈ comparator

Type A behaviour

Friedman 1982

54

Type A: Videotaped Clinical Interview for Type A behaviour

Mean (SD): 15.5 (8.9) vs 22.1 (9.7), P < 0.001

Intervention > comparator

Sebregts 2005

9

Type A: Revised Videotaped Structured Interview (Hostility subscale)

Mean (SD): 53.6 (25.3) vs 58.9 (29.5), P = 0.03

Intervention > comparator

9

Type A: Revised Videotaped Structured Interview (Time Urgency subscale)

Mean (SD): 66.5 (29.6) vs 75 (32.1), P = 0.01

Intervention > comparator

9

Type A: Revised Videotaped Structured Interview (Insecurity subscale)

Mean (SD): 25.8 (20.6) vs 26.3 (22.6), P = NS

Intervention ≈ comparator

Vital exhaustion

Sebregts 2005

9

Maastricht Questionnaire

Mean (SD): 4.6 (5.7) vs 4.7 (5.5), P = NS

Intervention ≈ comparator

Claesson 2005

12

Mean (SD): 12.2 (17.3) vs 15.8 (19.4), P < 0.05

Intervention > comparator

Koertge 2008

30

Mean (SD): 16.5 (11.1) vs 16.9 (11.3), P = 0.005

Intervention > comparatora

Roncella 2013

23

Mean (SD): 56.5 (8.1) vs 59.7 (14.5), P = NS

Intervention ≈ comparator

Hopelessness

Freedland 2009

9

Beck Hopelessness Scale

Mean (SD): CBT 3.5 (5.1); SSM 5.5 (5.8) vs 7.5 (6.0), P = NS

Intervention ≈ comparator

a The authors noted in their discussion that "due to regression towards the mean we cannot attribute the decrease in vital exhaustion to the intervention."

CBT: cognitive behavioural therapy; CI: confidence interval; DSM‐IV: Diagnostic and Statistical Manual of Mental Disorders ‐ 4th edition; IQR: interquartile range; OR: odds ratio; NR: not reported; NS: non‐significant (P >0.10); SD: standard deviation; SSM: supportive stress management; STAXI: Spielberger Anger scales (STAXI 1985).

Figures and Tables -
Table 1. Other psychological outcomes
Table 2. Health‐related quality of life (HRQoL) scores

Trial

Follow‐up (months)

Measure

Scores at follow‐up (mean (SD)): intervention vs comparator, P value

Between‐group differencea

Appels 2005

18

MacNew Questionnaire: Global Score

126.9 (27.4) vs 127.1 (25.8), P = NS

Intervention ≈ comparator

Claesson 2005

12

Swedish Quality of Life Scale

6.59 (2.95) vs 5.97 (3.15), P = NS

Intervention ≈ comparator

ENRICHD Investigators 2000

6

SF‐12: Physical Component Score

0.8 (23.0), P = NSb

Intervention ≈ comparator

6

SF‐12: Mental Component Score

2.2 (18.3), P < 0.05b

Intervention > comparator

6

Life Satisfaction Scale

1.0 (9.8), P < 0.05b

Intervention > comparator

6

Ladder of Life

0.3 (4.6), P < 0.05b

Intervention > comparator

Freedland 2009

9

SF‐36: Physical Component Score

CBT 37.6 (9.6); SSM 38.9 (9.7) vs 36.9 (10.6), P = NS

Intervention ≈ comparator

9

SF‐36 Mental Component Score

CBT 49.1 (12.2); SSM 47.8 (13.0) vs 42.4 (13.3), P = 0.01

Intervention > comparator

Lie 2007

6

SAQ: Physical Limitations

86.4 (15.6) vs 83.2 (18.7), P = NS

Intervention ≈ comparator

6

SAQ: Angina Frequency

91.7 (16.6) vs 90.8 (18.9), P = NS

Intervention ≈ comparator

6

SAQ: Treatment Satisfaction

89.2 (15.4) vs 88.0 (16.1), P = NS

Intervention ≈ comparator

6

SAQ: Disease Perception

77.8 (20.2) vs 3.9 (24.2), P = NS

Intervention ≈ comparator

6

SF‐36: Physical Component Score

47.4 (9.6) vs 47.0 (10.0), P = NS

Intervention ≈ comparator

6

SF‐36: Mental Component Score

52.1 (10.7) vs 50.5 (10.8), P = NS

Intervention ≈ comparator

Mayou 2002

12

Dartmouth COOP

14 (IQR 13 to 17) vs 15 (IQR 12.5 to 21), P = NSc

Intervention ≈ comparator

Michalsen 2005

12

SF‐36: Physical Component Score

43.2 (9.2) vs 46.1 (9.3), P = NS

Intervention ≈ comparator

12

SF‐36: Mental Component Score

47.2 (9.2) vs 49.3 (10), P = NS

Intervention ≈ comparator

O'Neil 2015

12

SF‐12: Physical Component Score

36.6 (10.5) vs 36.2 (10.5), P = NR

Intervention ≈ comparator

12

SF‐12: Mental Component Score

45.6 (9.3) vs 42.7 (11.1), P = NR

Intervention ≈ comparator

Rakowska 2015

30

SF‐36: Physical Component Score

64.3 (5.2) vs 61.7 (4.8), P = 0.04

Intervention > comparator

30

SF‐36: Mental Component Score

58.9 (5.9) vs 53.0 (2.2), P < 0.01

Intervention > comparator

Roncella 2013

12

MacNew Questionnaire: Global Score

6.07 (IQR 5.48 to 6.39) vs 5.67 (IQR 4.89 to 6.31), P = 0.07c

Intervention ≈ comparator

12

MacNew Questionnaire: Emotional Score

5.79 (IQR 5.36 to 6.35) vs 5.79 (IQR 5.0 to 6.32), P = NSc

Intervention ≈ comparator

12

MacNew Questionnaire: Physical Score

6.23 (IQR 5.70 to 6.53) vs 5.69 (IQR 4.85 to 6.29), P = 0.03c

Intervention > comparator

12

MacNew Questionnaire: Social Score

6.15 (IQR 5.69 to 6.61) vs 5.86 (IQR 5.0 to 6.46), P = 0.06c

Intervention ≈ comparator

a Intervention ≈ comparator (intervention and comparator equivalent); intervention > comparator (intervention superior to comparator group).

b Mean difference (SD).

c Median (IQR) and P value from Mann Whitney U test.

CBT: cognitive behavioural therapy; NS: non‐significant (P > 0.10); SAQ: Seattle Angina Questionnaire; SD: standard deviation; SF‐12: 12‐item Short Form; SF‐36: 36‐item Short Form; SSM: supportive stress management.

Figures and Tables -
Table 2. Health‐related quality of life (HRQoL) scores
Table 3. Total mortality: univariate meta‐regression results

Predictor

Total mortality
exp(β) (SE)

Explanatory variable codinga

Population targeted at baseline

Psychological disorder present

1.19 (0.18), P = 0.26

Non‐selected 0, present 1

Characteristics of psychological intervention

Mode of treatment

1.21 (0.18), P = 0.21

Individual 0, group 1, both 2

Family included

1.11 (0.19), P = 0.55

No 0, yes 1

CRF education included

0.92 (0.14), P = 0.58

No 0, yes 1

Intervention targeted behavioural change of CRFs

1.06 (0.16), P = 0.72

No 0, yes 1

Psychological treatment targets

Depression

1.28 (0.25), P = 0.22

No 0, yes 1

Anxiety

1.22 (0.23), P = 0.31

No 0, yes 1

Stress

1.28 (0.39), P = 0.43

No 0, yes 1

Type A behaviour

0.98 (0.15), P = 0.89

No 0, yes 1

Psychological components

Relaxation training

1.15 (0.22), P = 0.47

No 0, yes 1

Stress management techniques

1.15 (0.25), P = 0.54

No 0, yes 1

Cognitive challenge/restructuring techniques

1.10 (0.17), P = 0.53

No 0, yes 1

Emotional support or client‐led discussion, or both

1.42 (0.25), P = 0.07

No 0, yes 1

Adjunct pharmacology

2.08 (2.53), P = 0.56

No 0, yes 1

a If relevant information was not reported the study was coded as 0.

CRF: cardiac risk factor; SE: standard error.

Figures and Tables -
Table 3. Total mortality: univariate meta‐regression results
Table 4. Cardiac mortality: univariate meta‐regression results

Predictor

Cardiac‐mortality
exp(β) (SE)

Explanatory variable codinga

Population targeted at baseline

Psychological disorder present

1.17 (0.30), P = 0.58

Non‐selected 0, present 1

Characteristics of psychological intervention

Mode of treatment

1.19 (0.32), P = 0.56

Individual 0, group 1, both 2

Family includedb

0.82 (0.09), P = 0.13

No 0, yes 1

CRF education included

0.84 (0.24), P = 0.57

No 0, yes 1

Intervention targeted behavioural change of CRFs

1.17 (0.49), P = 0.72

No 0, yes 1

Psychological treatment targets

Depression

1.13 (0.31), P = 0.67

No 0, yes 1

Anxiety

1.13 (0.31), P = 0.67

No 0, yes 1

Stress

1.24 (0.71), P = 0.72

No 0, yes 1

Type A behaviour

1.02 (0.46), P = 0.95

No 0, yes 1

Psychological components

Relaxation training

1.27 (0.74), P = 0.70

No 0, yes 1

Stress management techniques

1.03 (0.46), P = 0.95

No 0, yes 1

Cognitive challenge/restructuring techniques

1.11 (0.40), P = 0.78

No 0, yes 1

Emotional support or client‐led discussion, or both

1.16 (0.30), P = 0.58

No 0, yes 1

Adjunct pharmacologyb

0.82 (0.9), P = 0.13

No 0, yes 1

a If relevant information was not reported the variable/study was coded as 0.

b 'Yes' category (coded 1) contained no participants. Data reported from a model including 'no' (coded 0) only.

CRF: cardiac risk factor; SE: standard error.

Figures and Tables -
Table 4. Cardiac mortality: univariate meta‐regression results
Table 5. Depression: univariate meta‐regression results

Predictor

Depression
exp(β) (SE)

Explanatory variable codinga

Population targeted at baseline

Psychological disorder present

‐0.20 (0.12), P = 0.10

Non‐selected 0, present 1

Characteristics of psychological intervention

Mode of treatment

0.007 (0.09), P = 0.94

Individual 0, group 1, both 2

Family included

0.06 (0.14), P = 0.70

No 0, yes 1

CRF education included

0.06 (0.13), P = 0.65

No 0, yes 1

Intervention targeted behavioural change of CRFs

‐0.16 (0.12), P = 0.20

No 0, yes 1

Psychological treatment targets

Depression

0.15 (0.13), P = 0.26

No 0, yes 1

Anxiety

0.18 (0.12), P = 0.17

No 0, yes 1

Stress

0.13 (0.13), P = 0.35

No 0, yes 1

Type A behaviour

‐0.65 (0.14), P = 0.65

No 0, yes 1

Psychological components

Relaxation training

‐0.09 (0.13), P = 0.50

No 0, yes 1

Stress management techniques

0.09 (0.13), P = 0.52

No 0, yes 1

Cognitive challenge/restructuring techniques

0.07 (0.14), P = 0.59

No 0, yes 1

Emotional support or client‐led discussion, or both

0.14 (0.13), P = 0.28

No 0, yes 1

Adjunct pharmacology

‐0.51 (0.15), P = 0.003

No 0, yes 1

a If relevant information was not reported the variable/study was coded as 0.

CRF: cardiac risk factor; SE: standard error.

Figures and Tables -
Table 5. Depression: univariate meta‐regression results
Table 6. Anxiety: univariate meta‐regression results

Predictor

Anxiety
exp(β) (SE) P value

Explanatory variable codinga

Population targeted at baseline

Psychological disorder present

‐0.28 (0.11), P = 0.03

Non‐selected 0, present 1

Characteristics of psychological intervention

Mode of treatment

0.09 (0.09), P = 0.30

Individual 0, group 1, both 2

Family included

0.24 (0.12), P = 0.06

No 0, yes 1

CRF education included

0.18 (0.13), P = 0.21

No 0, yes 1

Intervention targeted behavioural change of CRFs

‐0.08 (0.17), P = 0.61

No 0, yes 1

Psychological treatment targets

Depression

‐0.04 (0.16), P = 0.83

No 0, yes 1

Anxiety

0.05 (0.15), P = 0.78

No 0, yes 1

Stress

0.18 (0.13), P = 0.20

No 0, yes 1

Type A behaviour

‐01 (0.26), P = 0.97

No 0, yes 1

Psychological components

Relaxation training

0.15 (0.14), P = 0.29

No 0, yes 1

Stress management techniques

‐0.03 (0.15), P = 0.87

No 0, yes 1

Cognitive challenge/restructuring techniques

‐0.16 (0.14), P = 0.29

No 0, yes 1

Emotional support or client‐led discussion, or both

0.12 (0.14), P = 0.44

No 0, yes 1

Adjunct pharmacology

‐0.12 (0.24), P = 0.65

No 0, yes 1

a If relevant information was not reported the variable/study was coded as 0.

CRF: cardiac risk factor; SE: standard error.

Figures and Tables -
Table 6. Anxiety: univariate meta‐regression results
Comparison 1. Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation)

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1.1 Total mortality Show forest plot

23

7776

Risk Ratio (M‐H, Random, 95% CI)

0.90 [0.77, 1.05]

1.2 Cardiac mortality Show forest plot

11

4792

Risk Ratio (M‐H, Random, 95% CI)

0.79 [0.63, 0.98]

1.3 Revascularisation (coronary artery bypass graft surgery and percutaneous coronary intervention combined) Show forest plot

13

6822

Risk Ratio (M‐H, Random, 95% CI)

0.94 [0.81, 1.11]

1.4 Non‐fatal myocardial infarction Show forest plot

13

7845

Risk Ratio (M‐H, Random, 95% CI)

0.82 [0.64, 1.05]

1.5 Depression Show forest plot

19

5825

Std. Mean Difference (IV, Random, 95% CI)

‐0.27 [‐0.39, ‐0.15]

1.6 Anxiety Show forest plot

12

3161

Std. Mean Difference (IV, Random, 95% CI)

‐0.24 [‐0.38, ‐0.09]

1.7 Stress Show forest plot

8

1251

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.88, ‐0.24]

Figures and Tables -
Comparison 1. Psychological intervention (alone or with other rehabilitation) versus comparator (usual care or other rehabilitation)