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Increased longevity and the development of sophisticated healthcare technologies and treatments mean that many people now live with chronic health conditions such as cardiovascular disease over extended periods of their lives. In this context, health-related quality of life (HRQoL) has become an important endpoint in evaluations of health interventions. Its use reflects an increasingly biopsychosocial perspective in modern healthcare. HRQoL research first developed in cancer settings where the balance of quality and duration of life became a key concern in decisions to use novel treatments with very serious side-effects and only partial efficacy. However, over the past 20 years there has been a burgeoning of research activity in every major chronic illness category. In cancer, the European Organisation for Research on the Treatment of Cancer (EORTC) has been established by interested professionals.

The search for psychological factors involved in the development and/or progression of coronary heart disease (CHD) has been a fairly persistent, although not always fruitful, activity over the last few decades. Both the clinical observation that CHD patients seem to exhibit certain psychological profiles and the apparent failure of traditional risk factors, such as smoking, high blood pressure and cholesterol, and low levels of physical exertion, to predict anywhere near all new instances of CHD have helped fuel an expectation that there may be other, psychological, predisposing factors at work.

Which conclusions can be drawn from these clinical observations? One key message is that educating patients and spouses with the purpose of optimizing rehabilitation and secondary prevention is not just a matter of informing about facts. It is a process where professional caregivers must be sensitive to the social and emotional reality of the patient and spouse. Caregivers must also be very aware of the communicative interplay and the fact that both patient and spouse cognitions and interpretations may be very different from those of the professional. To health professionals, cardiological and surgical procedures are relatively routine aspects of their daily work. However, these procedures are not routine to the patient and his or her family — to them, it is a profoundly life-changing experience, and emotionally and spiritually a brush with death.

Early models of stress considered it to arise from our environment, and to impact on us all equally. Holmes and Rahe1 established a hierarchy of severity for various stressors. They also attempted to provide a link between stress and health, suggesting that the more stressful life events an individual experiences, the more their risk of ill-health. Unfortunately, this hypothesis was rarely substantiated. What has emerged from subsequent research is that the impact of potentially stressful events is mediated by our psychological responses to those events. The meaning attributed to events, and the coping responses we use, profoundly influence our emotional and behavioral responses to them. Accordingly, more recent models of stress consider stress to have a number of components: a cognitive response (“I am worried I won’t cope with this problem”), a physiological component usually involving increased autonomic arousal, a behavioral element involving more or less useful coping responses, and an emotional experience involving a variety of negative emotional states such as anger or anxiety (Figure 34-1).

The WHO defines adherence as “the extent to which a person’s behaviour — taking medication, following a diet, and/o r executing lifestyle changes, corresponds with agreed recommendations from a health care provider” (p. 3). There are numerous ways in which behavior may not correspond with recommendations: non-adherence comprises behaviors such as not commencing performance of a recommended behavior (e.g. not exercising), cessation of a behavior too soon (e.g. stopping medication prematurely), no t performing enough of the behavior (e.g. taking insufficient exercise to gain a benefit), and inconsistently performing the behavior (e.g. taking some medications some of the time). A distinction is made between intentional and unintentional nonadherent behaviors.

Cardiac rehabilitation services have developed worldwide over the last few decades. The World Health Organization definitions of cardiac rehabilitation of 1969 and 1993 outlined what was required of a cardiac rehabilitation service for patients with coronary heart disease. However, as might be expected, different countries and health provision services developed different styles of programs in response to local funding, available staff, and patient profiles. As a result of this, many international bodies developed their own guidelines and policies for the provision of cardiac rehabilitation.– The CARINEX survey of current guidelines and practices within the European Union identified 20 professional guidelines since 1990, in nine languages across Europe alone. Twelve separate countries had national guidelines.

Heart failure is a serious condition. More than two-thirds of individuals with moderate to severe systolic dysfunction are hospitalized yearly and one out of three die within one year after hospitalization. The heart failure group consumes >2% of the total healthcare costs and the main costs are due to hospitalizations.,

One of the main goals of a cardiac rehabilitation (CR) program is to support the patient in returning to work: strong economic and quality of life arguments exist. It has been stated that patients after an acute myocardial infarction (MI) without complications such as left ventricular dysfunction or exercise-induced myocardial ischemia may safely resume their previous work: for light office work 2 weeks of sickness absence are recommended, for average manual work 3 weeks, and for strenuous physical work 6 weeks. Thus, a majority of MI patients may well return to work (RTW) within the first month after discharge from hospital, as almost all industrial and other jobs require significantly less effort than the average maximum work capacity of a healthy population: only 25% is generally demanded for the modern workplace.

One of the objectives of coronary interventions is to enable patients to return to work. This is also one of the aims of the cardiac rehabilitation programs offered to these patients. The inability to resume professional activities after coronary interventions may constitute a stress (and therefore a risk factor) for the patient due to a loss of self-esteem and earnings.

It is often expected that among seriously ill patients sexuality is not important. However, satisfaction with sexual functioning is recognized as a component that influences quality of life. Studies show that patients who are chronically or critically ill are concerned about sexual dysfunction. Sexual function has been studied in some chronic disease states, especially in diabetes, cancer, spinal cord injury, and some cardiac diseases. For example, sexual function in patients after myocardial infarction (MI) or after coronary artery bypass grafting (CABG) has been studied since the 1970s and 1980s. More recently sexual function in patients with heart transplantation or heart failure has been studied. It is known that there are many important links between sexual activity and heart disease: