The impact of psychological support strategies on clinical outcomes and quality of life in patients with chronic heart disease: a randomized controlled trial - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice J Cardiothorac Surg . 2026 Mar 9;21:190. doi: 10.1186/s13019-026-03858-8 Search in PMC Search in PubMed View in NLM Catalog Add to search The impact of psychological support strategies on clinical outcomes and quality of life in patients with chronic heart disease: a randomized controlled trial Yanmei Zhang Yanmei Zhang 1 Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 P. R. China Find articles by Yanmei Zhang 1 , Yuan Liang Yuan Liang 1 Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 P. R. China Find articles by Yuan Liang 1 , Haixia Huang Haixia Huang 1 Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 P. R. China Find articles by Haixia Huang 1 , Yulan Xu Yulan Xu 2 Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 P. R. China Find articles by Yulan Xu 2, ✉ Author information Article notes Copyright and License information 1 Department of Cardiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 P. R. China 2 Department of Nursing, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022 P. R. China ✉ Corresponding author. Received 2025 Jun 17; Accepted 2026 Jan 24; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13085507 PMID: 41803954 Abstract Background As chronic heart disease (CHD) continues to rise globally, attention is shifting beyond medical interventions to the psychological dimensions of care. This study examined whether structured psychological support, integrated within a multidisciplinary framework, could enhance clinical outcomes, promote healthier lifestyles, and improve quality of life among CHD patients. Methods In a randomized controlled trial, 200 patients with CHD were allocated to either an intervention group—receiving psychological support, educational sessions, dietary counseling, and personalized physical activity—or a control group receiving standard care. The primary outcomes were changes in lipid profiles and cardiac imaging after 12 months. Secondary measures included cardiac events, health-related quality of life (HRQoL), medication adherence, and lifestyle behaviors assessed at 6 and 12 months. Analyses followed the intention-to-treat principle. Results The intervention group demonstrated better lipid outcomes at 12 months significantly, including lower LDL cholesterol (90 ± 25 vs. 100 ± 30 mg/dL) and higher HDL cholesterol (50 ± 12 vs. 45 ± 10 mg/dL). Cardiac imaging also improved, with higher left ventricular ejection fraction (56.2 ± 6.1% vs. 54.1 ± 6.3%) and lower left atrial volume index (28 ± 7 vs. 32 ± 8 mL/m²). Quality-of-life scores were higher across all SF-36 domains (e.g., mental health: 78 ± 10 vs. 64 ± 15), and psychological outcomes were more favorable, with lower depression (5.4 ± 2.1 vs. 7.8 ± 2.5) and anxiety scores (4.9 ± 1.9 vs. 7.2 ± 2.3). Medication adherence was also higher (91 ± 6 vs. 75 ± 13), and functional capacity improved (390 ± 45 vs. 350 ± 60 m on the 6-minute walk test). Conclusion Embedding psychological support within cardiology care delivers potential benefits in lipid regulation, cardiac performance, and quality of life for CHD patients. These findings highlight the critical role of integrated, patient-centred approaches in optimizing long-term outcomes in cardiac care. Supplementary Information The online version contains supplementary material available at 10.1186/s13019-026-03858-8. Keywords: Chronic heart disease, Psychological support, Cardiology nursing, Cardiac rehabilitation, Quality of life Introduction Chronic heart disease (CHD) remains a leading cause of morbidity and mortality worldwide and reflects a complex interplay of biological, behavioral, and psychosocial determinants [ 1 ]. Managing CHD requires not only optimal medical therapy but also attention to the psychological well-being of patients, as emotional distress can adversely affect disease management and overall prognosis [ 2 ]. Anxiety, depression, and stress are highly prevalent among patients with CHD and are strongly associated with poorer adherence to treatment, unhealthy lifestyle behaviors, recurrent cardiovascular events, and reduced quality of life [ 3 , 4 ]. Globally, cardiovascular diseases accounted for approximately 17.7 million deaths in 2015, with coronary artery disease responsible for over 7 million of these fatalities [ 4 ]. This high burden underscores the need to consider psychological as well as physiological contributors to cardiac outcomes [ 3 ]. Several mechanisms explain how psychological distress may worsen cardiovascular disease, including autonomic nervous system dysregulation, hypothalamic–pituitary–adrenal axis activation, systemic inflammation, altered lipid metabolism, and impaired vascular reactivity [ 5 ]. These biological pathways interact with behavioral risk factors—such as reduced physical activity and poor medication adherence—further highlighting the potential value of psychological support within CHD management frameworks [ 6 ]. Psychiatric conditions such as depression and anxiety are also major global health concerns, affecting millions worldwide and contributing to substantial mortality and disability [ 7 , 8 ]. Despite the well-established links between psychological distress and cardiovascular risk, relatively few studies have evaluated structured psychological support delivered as part of a multidisciplinary cardiac care model [ 2 , 9 ]. Recent evidence emphasizes that optimal cardiac care requires integrated approaches that combine psychological support, education, and self-care enhancement. A recent Cochrane review showed that structured psychological interventions can meaningfully reduce depression and anxiety and improve quality of life in patients with coronary heart disease and heart failure [ 10 ]. Multidisciplinary, nurse-led models have also demonstrated benefits for self-care, symptom management, and psychosocial support in heart failure populations [ 11 ]. Furthermore, person-centered analyses from trials such as MOTIVATE-HF indicate that psychological distress and inadequate self-care often coexist, underscoring the need for interventions that address these domains simultaneously [ 12 ]. Complementary findings from cardiac telerehabilitation studies show that programs incorporating education, behavioral guidance, and ongoing support can improve quality of life and adherence following cardiac events [ 13 ]. Existing interventions often focus on single components of cardiac rehabilitation—such as exercise or dietary modification—rather than integrating psychological support with education, behavior change, and lifestyle counseling. Although psychosocial interventions and cardiac rehabilitation programs have been studied, most prior trials have examined isolated components—such as stress-management training, exercise rehabilitation, or dietary counseling—instead of a coordinated, multidisciplinary model that integrates psychological support into routine cardiology nursing [ 14 , 15 ]. Moreover, few randomized trials have evaluated whether embedding structured psychological strategies within nurse-led cardiac care improves both clinical outcomes and patient-reported measures simultaneously [ 16 ]. This lack of comprehensive, integrated approaches represents a key evidence gap that the present study seeks to address. To address this gap, the present randomized controlled trial evaluates the added value of structured psychological support integrated into cardiology nursing—alongside contributions from dietitians, cardiologists, and physiotherapists—to holistically address the physical and psychological needs of patients with chronic heart disease. Materials and methods Study design This study was a randomized controlled trial (RCT) designed to assess the efficacy of a comprehensive intervention in enhancing clinical outcomes for patients with chronic heart disease. Conducted between January 2022 and December 2023, participants were recruited from outpatient cardiology clinics and were randomized in a 1:1 ratio to either the intervention or control group through a computer-generated randomization scheme. Outcome data assessors were blinded to group assignments. Participants Eligible participants were adults aged 40 to 75 years with a documented history of chronic heart disease, defined by previous myocardial infarction, stable angina, or a diagnosis of heart failure. Exclusion criteria included terminal illness, cognitive impairment preventing informed consent, or any concurrent participation in another clinical trial. Recruitment was conducted by trained research coordinators who screened potential participants for eligibility based on their medical records and a preliminary health questionnaire. The target sample size of 200 participants (100 per group) was determined based on feasibility constraints and effect sizes reported in previous trials evaluating psychosocial or behavioral interventions in patients with chronic heart disease. While no published randomized trial exactly matches the present design ( n ≈ 200, integrated psychological + lifestyle + imaging endpoints), Prior behavioral and psychosocial intervention trials in cardiac populations commonly report moderate effect sizes for lipid parameters and functional outcomes [ 17 – 19 ]. Using these estimates, a sample of 200 participants was expected to provide adequate statistical power (approximately 80%) to detect clinically meaningful between-group differences in primary outcomes such as LDL cholesterol and left ventricular ejection fraction, assuming a moderate effect size (d = 0.4–0.5) and a two-sided α of 0.05. The sample size also accounted for an anticipated attrition rate of 10–15% over the 12-month follow-up period, which is common in multidisciplinary and behavior-focused interventions. Although not based on a single formal power calculation, the selected sample size reflects a pragmatic balance between statistical considerations, anticipated recruitment rates, and the operational demands of delivering a year-long, multidisciplinary intervention. Interventions Participants in the intervention group received a structured, multidisciplinary program designed to support both physical and psychological aspects of CHD management. The intervention lasted 12 months and included four core components: health education, dietary counseling, individualized exercise programs, and psychological support. Health education sessions Monthly 60-minute group sessions were conducted by a cardiologist, dietitian, and physiotherapist. These sessions focused on understanding CHD, the importance of medication adherence, and strategies for risk factor management. Additional topics included blood pressure and lipid control, smoking cessation, and the role of physical activity. Stress management techniques—such as mindfulness, breathing exercises, and guided relaxation—were also introduced. Sessions incorporated interactive components, including real-time Q&A, practical demonstrations (e.g., food label reading), and scenario-based discussions to enhance engagement and knowledge retention. Dietary counseling Each participant underwent an initial one-on-one assessment with a registered dietitian to identify dietary patterns and cardiometabolic risks. Based on this, a personalized nutrition plan was developed with an emphasis on the Mediterranean diet—rich in fruits, vegetables, whole grains, legumes, lean proteins, and healthy fats (e.g., olive oil and nuts). The counseling addressed specific goals such as reducing LDL cholesterol, managing blood glucose levels, and supporting weight control. Participants received guidance on portion sizes, meal preparation, grocery planning, and behavioral strategies to improve eating habits. Follow-up sessions occurred bi-monthly to track progress and adjust plans as needed. Individualized exercise programs A certified physiotherapist evaluated each participant’s cardiovascular fitness, flexibility, and muscle strength to create a tailored physical activity plan. Regimens included moderate-intensity aerobic exercises—such as walking, cycling, or swimming—combined with resistance training. Participants were encouraged to gradually reach the target of at least 150 min of aerobic activity per week, in accordance with the American Heart Association guidelines. Monthly reassessments allowed for program adjustments and provided support for overcoming barriers to adherence. Psychological support The psychological support component was grounded in the established Motivational Interviewing (MI) framework described by Miller and Rollnick, emphasizing autonomy support, exploration of ambivalence, intrinsic motivation, and strengthening of self-efficacy [ 20 , 21 ]. In addition to MI, the intervention incorporated core principles of Cognitive-Behavioral Therapy (CBT), which is a structured, evidence-based approach targeting unhelpful patterns of thinking and behavior that may hinder effective cardiac self-management [ 22 ]. The CBT strategies integrated into the biweekly sessions included cognitive restructuring to help participants identify and modify negative automatic thoughts related to their illness or their ability to maintain lifestyle changes, behavioral activation to encourage engagement in health-promoting routines, and problem-solving techniques aimed at overcoming barriers to medication adherence, dietary modification, or physical activity. Stress-management approaches, including controlled breathing and strategies to manage emotional triggers, were also used to enhance coping capacity. All sessions were delivered by a clinical psychologist using a structured intervention guide to ensure consistency across participants. Fidelity to MI and CBT principles was monitored through regular supervision meetings with a senior psychologist experienced in these therapeutic modalities and through periodic review of anonymized session documentation, which allowed assessment of adherence to core MI communication strategies and accurate application of CBT-based techniques. Control group Participants in the control group received standard care, including regular medical follow-up, routine lifestyle advice, and access to general healthcare services, but no structured psychological or behavioral interventions. Concomitant care Both groups continued to receive standard cardiology care, including routine clinical follow-up, medication management, and lifestyle counseling as recommended by their treating cardiologists. No additional therapies, medications, or care strategies differed between groups outside of the psychological support sessions provided to the intervention group. Concomitant care was therefore comparable across study arms. Outcomes Primary outcomes were changes in laboratory values (LDL cholesterol, HDL cholesterol, triglycerides, HbA1c, serum potassium, and C-Reactive Protein) and cardiac imaging outcomes (left ventricular ejection fraction and left atrial volume index) at 1-year follow-up. Secondary outcomes included the incidence of cardiac events (non-fatal MI, unstable angina, heart failure hospitalization, and stroke) at 12 months and HRQoL was evaluated using the 36-Item Short Form Health Survey (SF-36), a widely validated instrument comprising eight domains that assess physical, emotional, and social functioning. Tertiary outcomes were medication adherence and lifestyle changes measured at 6 and 12 months. To avoid ambiguity regarding outcome hierarchy, lipid profile parameters (LDL and HDL cholesterol) and cardiac imaging indices (left ventricular ejection fraction and left atrial volume index) were prespecified as the primary outcomes before data collection. All other endpoints—including HRQoL, medication adherence, depression and anxiety scores, blood pressure, functional capacity, lifestyle behaviors, readmission, and event-free survival—were designated as secondary or exploratory outcomes. Because statistical testing was centered on a limited number of primary outcomes, we did not apply formal corrections for multiple comparisons across secondary variables. Instead, secondary outcomes are interpreted as supportive and hypothesis-generating, consistent with recommendations for multidomain behavioral and psychosocial intervention trials. This approach mitigates the risk of Type I error inflation while preserving clinical interpretability across diverse health domains. Data collection Baseline characteristics were collected at the initial visit, including demographics, medical history, and current medications. Laboratory values were measured at baseline and at 1-year follow-up. Cardiac imaging was performed at baseline and at 1 year using standardized echocardiographic methods. Clinical events were tracked through patient records and confirmed by a clinical events committee. HRQoL was assessed using self-administered questionnaires at baseline and at 12 months. Medication adherence was measured using a validated scale, and lifestyle changes were assessed through self-reports and clinical interviews. Statistical analysis Statistical analyses were conducted using the latest version of SPSS software. Continuous variables were summarized using means and standard deviations, and categorical variables using frequencies and percentages. Between-group differences were assessed using independent t-tests for continuous variables and chi-square tests for categorical variables. A two-sided p-value of less than 0.05 was considered statistically significant. Multiple regression analyses were performed to adjust for potential confounders. The intention-to-treat principle was applied for all analyses. In analysing the study results, several potential confounders and covariates were identified and controlled to minimize their impact on the findings. These included: Age and Gender: Given the variation in the prevalence and progression of chronic heart disease by age and gender, these were included as covariates in all statistical models to ensure that the outcomes were not biased by these demographic factors. Baseline Disease Severity: The severity of heart disease at baseline was accounted for, as it could influence both the progression of the disease and the responsiveness to the intervention. This was measured using baseline scores of left ventricular ejection fraction and the presence of comorbid conditions such as diabetes and hypertension. Smoking Status and Alcohol Consumption: Lifestyle factors such as smoking and alcohol use have significant effects on heart disease progression and outcomes. These were recorded at baseline and included as covariates in the regression analyses to adjust for potential confounding effects. Medication Adherence: Before the intervention, baseline medication adherence was assessed using a validated scale. This factor was crucial to control for, as initial non-adherence could skew the effectiveness of the psychological support interventions to improve this outcome. Physical Activity Level: Participants’ baseline physical activity levels were assessed through a standardized questionnaire. Given the strong influence of physical activity on cardiovascular health, this variable was controlled in the analysis to isolate the effect of the intervention on the impact of pre-existing activity habits. No missing outcome data were observed for primary or secondary endpoints. All participants completed baseline, 6-month, and 12-month assessments, and all variables included in the analyses had complete datasets. Therefore, no imputation procedures were required, and all analyses were conducted using complete cases. Ethics The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the appropriate ethics committee. The study’s protocol received approval from the Institutional Review Board (IRB). This study was conducted as part of a hospital-based quality-improvement and clinical service-enhancement initiative. At the time of study initiation, registration in a public trials registry was not mandatory for non-pharmacological behavioral interventions conducted within institutional clinical programs, and the project was approved locally as a service-development activity with research components. For this reason, prospective trial registration was not performed. Consent to participate All participants were informed about the nature, purpose, potential risks, and benefits of the study. Written informed consent was obtained from each participant before enrollment. Participation was voluntary, and individuals were allowed to withdraw from the study at any point without any impact on their standard medical care. Results A total of 260 individuals were screened for eligibility, of whom 200 met the inclusion criteria and were randomized equally to the intervention ( n = 100) and control ( n = 100) groups. All participants received their assigned intervention, and no losses to follow-up or withdrawals occurred throughout the 12-month study period. Accordingly, all randomized participants were included in the final analyses. The CONSORT flow diagram provides a detailed overview of participant recruitment, allocation, follow-up, and analysis. (Fig. 1 ). Fig. 1. Open in a new tab CONSORT 2010 Flow Diagram All outcomes described in the text are presented in tabular form in Tables 1 , 2 , 3 and 4 and Supplementary Tables 1–3. Table 1. Baseline characteristics of study participants Characteristic Intervention Group ( n = 100) Control Group ( n = 100) p -value Age (years) 63.2 ± 8.4 64.1 ± 7.8 0.321 Gender (Female, %) 45 50 0.483 BMI (kg/m²) 28.5 ± 4.2 29.1 ± 3.9 0.255 Smoking History (Yes, %) 20 25 0.349 Diabetes Mellitus (Yes, %) 30 35 0.397 Hypertension (Yes, %) 60 65 0.456 Previous MI (Yes, %) 40 42 0.781 Ejection Fraction (%) 55.3 ± 6.5 54.8 ± 6.9 0.635 NYHA Class 0.723 - I (%) 25 28 - II (%) 40 37 - III (%) 30 29 - IV (%) 5 6 Open in a new tab BMI: body mass index; NYHA: No symptoms of heart failure; Note: Data expressed as mean and standard deviation and percentage Table 2. Follow-Up laboratory tests values Laboratory Test Intervention Group (Mean ± SD) Control Group (Mean ± SD) p -value 95% CI for Mean Difference LDL Cholesterol (mg/dL) 90 ± 25 100 ± 30 0.046 -19.9 to -0.1 HDL Cholesterol (mg/dL) 50 ± 12 45 ± 10 0.033 0.9 to 9.1 Triglycerides (mg/dL) 150 ± 45 170 ± 50 0.089 -44.2 to 4.2 HbA1c (%) 6.5 ± 0.9 6.8 ± 1.1 0.112 -0.7 to 0.1 Serum Potassium (mmol/L) 4.2 ± 0.3 4.3 ± 0.4 0.254 -0.2 to 0.1 C-Reactive Protein (mg/L) 3.0 ± 2.0 4.5 ± 3.0 0.005 -2.5 to -0.5 Open in a new tab LDL: low density cholesterol; HDL: high density cholesterol; CI: confidence interval Table 3. Incidence of cardiovascular events at 12 months Cardiac Event Intervention Group ( n = 100) Control Group ( n = 100) p -value Odds Ratio (95% CI) Non-fatal MI 5 15 0.017 0.31 (0.11–0.87) Unstable Angina 10 20 0.044 0.46 (0.21–0.98) Heart Failure Hospitalization 8 18 0.023 0.41 (0.18–0.92) Vascular Event Stroke 3 8 0.158 0.36 (0.10–1.29) Open in a new tab Table 4. Health-Related quality of life scores at 12 months HRQoL Score Intervention Group (Mean ± SD) Control Group (Mean ± SD) p -value Effect Size (Cohen’s d) Physical Functioning 80 ± 10 70 ± 15 < 0.001 0.76 Role Physical 75 ± 15 65 ± 20 0.002 0.57 Bodily Pain 75 ± 12 60 ± 18 < 0.001 0.94 General Health 72 ± 10 62 ± 16 0.001 0.71 Vitality 70 ± 10 55 ± 20 < 0.001 0.88 Social Functioning 80 ± 12 68 ± 18 < 0.001 0.78 Role Emotional 77 ± 13 65 ± 20 0.003 0.68 Mental Health 78 ± 10 64 ± 15 < 0.001 1.05 Open in a new tab Baseline characteristics Baseline characteristics were comparable between the two groups (Table 1 ). The mean age was 63.2 ± 8.4 years in the intervention group and 64.1 ± 7.8 years in controls. Sex distribution, BMI, smoking status, prevalence of diabetes and hypertension, previous MI, and baseline ejection fraction showed no statistically significant differences. Laboratory outcomes At 12 months, the intervention group showed a significantly better lipid profile. LDL cholesterol was lower (90 ± 25 vs. 100 ± 30 mg/dL; p = 0.046) and HDL cholesterol was higher (50 ± 12 vs. 45 ± 10 mg/dL; p = 0.033) compared with controls. C-reactive protein was also significantly reduced (3.0 ± 2.0 vs. 4.5 ± 3.0 mg/L; p = 0.005). Differences in triglycerides, HbA1c, and potassium were directionally favorable but did not reach statistical significance (Table 2 ). Cardiovascular and vascular events Cardiac events were significantly lower in the intervention group (Table 3 ). Non-fatal MI occurred in 5% vs. 15% of controls ( p = 0.017), unstable angina in 10% vs. 20% ( p = 0.044), and heart-failure hospitalization in 8% vs. 18% ( p = 0.023). Stroke—reported separately as a vascular event—occurred in 3% vs. 8% ( p = 0.158). Cardiac imaging outcomes At 12 months, the intervention group demonstrated modest but significant improvements in cardiac structure and function (Supplementary Table 1). Left ventricular ejection fraction increased to 56.2 ± 6.1% compared with 54.1 ± 6.3% in controls ( p = 0.044). Left atrial volume index was lower (28 ± 7 vs. 32 ± 8 mL/m²; p = 0.022). Right ventricular systolic pressure was also reduced (28 ± 5 vs. 31 ± 6 mmHg; p = 0.036). Health-related quality of life Health-related quality of life improved substantially across all SF-36 domains (Table 4 ). Notable differences included: Physical functioning: 80 ± 10 vs. 70 ± 15 ( p < 0.001). Vitality: 70 ± 10 vs. 55 ± 20 ( p < 0.001). Mental health: 78 ± 10 vs. 64 ± 15 ( p < 0.001). Effect sizes were moderate to large (Cohen’s d: 0.57–1.05), indicating strong clinical impact. Psychological outcomes Significant reductions in psychological distress were observed (Supplementary Table 3). Depression scores (HADS) were 5.4 ± 2.1 in the intervention group vs. 7.8 ± 2.5 in controls ( p < 0.001), and anxiety scores were 4.9 ± 1.9 vs. 7.2 ± 2.3 ( p < 0.001). Quality-of-life composite scores (SF-36 total) were higher (70.3 ± 8.8 vs. 60.1 ± 9.5; p < 0.001 (Supplementary Table 3). Blood pressure and functional capacity Systolic blood pressure was significantly lower in the intervention group (128 ± 12 vs. 135 ± 16 mmHg; p = 0.023) with a similar pattern in diastolic pressure (80 ± 8 vs. 85 ± 10 mmHg; p = 0.037). Participants also performed better in the 6-minute walk test (390 ± 45 vs. 350 ± 60 m; p = 0.002). Medication adherence and lifestyle behaviors Medication adherence improved markedly. At 6 months, scores reached 88 ± 7 vs. 72 ± 14 ( p < 0.001), and at 12 months 91 ± 6 vs. 75 ± 13 ( p < 0.001) (Supplementary Table 2). Lifestyle change scores followed a similar pattern, with significant improvements at both time points (Supplementary Table 2). Readmission and event-free survival The intervention group had a significantly lower hospital readmission rate (15 ± 5% vs. 25 ± 7%; p = 0.045) and higher 1-year event-free survival (85% vs. 65%; p = 0.012). Cardiac self-efficacy scores were also higher (34 ± 4 vs. 28 ± 5; p = 0.001), indicating improved confidence in disease self-management (Supplementary Table 3). Harms and unintended effects No harms, adverse events, or unintended effects related to the psychological support or usual-care procedures were reported in either group throughout the 12-month follow-up period. No participant required discontinuation or modification of the assigned intervention due to safety concerns. Discussion Interpretation of findings The intervention group demonstrated meaningful improvements in lipid profiles, with a significant reduction in LDL cholesterol and a notable increase in HDL cholesterol. These changes are clinically important, reflecting a lower atherogenic risk and improved cardiovascular protection. Although the observed reductions in triglycerides and HbA1c did not reach statistical significance, their downward trends suggest potential long-term metabolic benefits. Cardiac function also improved substantially among intervention participants, as evidenced by increased left ventricular ejection fraction and decreased left atrial volume index. These echocardiographic findings indicate reduced cardiac remodeling and better management of heart failure symptoms. In contrast, right ventricular systolic pressure remained unchanged, implying that the intervention’s primary effects may be confined to left heart parameters—an area for further exploration. Crucially, the incidence of adverse cardiac events was lower in the intervention group, with fewer non-fatal myocardial infarctions and heart failure hospitalizations. Although the reduction in stroke incidence did not reach statistical significance, the overall trend supports a protective cardiovascular effect of the comprehensive intervention. These outcomes point to both clinical and economic benefits, including reduced acute care utilization and a favourable trend toward better event-free survival. The improvements observed in psychological outcomes and health-related behaviors in our intervention group are consistent with recent literature emphasizing integrated self-care and psychosocial models in cardiac populations. The updated Cochrane review confirms that structured psychological interventions yield clinically meaningful reductions in depression and anxiety and improve mental quality of life in patients with coronary heart disease and heart failure, particularly when the intervention actively targets psychological symptoms [ 10 ]. Our findings also align with evidence highlighting the pivotal role of nurses and multidisciplinary teams in supporting symptom monitoring, lifestyle change, and psychosocial well-being across the continuum of cardiac care [ 11 ]. Person-centered analyses, such as the MOTIVATE-HF study, further demonstrate that psychological distress frequently co-occurs with poor self-care behaviors and reduced quality of life, reinforcing the relevance of interventions that simultaneously address emotional resilience and daily management demands in chronic cardiac conditions [ 12 ]. In addition, our results echo recent systematic reviews showing that structured, behaviorally oriented rehabilitation strategies—including home-based and technology-supported models—can improve quality of life, adherence, and functional capacity following cardiac events [ 13 ]. Together, these contemporary findings support the interpretation that the multidomain psychological support integrated in our program addresses well-recognized determinants of cardiac outcomes and contributes meaningfully to patient recovery. Beyond physiological outcomes, the intervention delivered significant gains in HRQoL. Improvements were seen across all SF-36 domains—physical functioning, vitality, social and emotional well-being—highlighting the holistic impact of integrating psychological and behavioral support into cardiac care. The medium to large effect sizes further underscores the clinical relevance of these changes. Higher scores in medication adherence and lifestyle modifications at both 6 and 12 months reinforce the role of motivational interviewing and structured education in promoting long-term self-care. These findings emphasize that improving psychological resilience and patient engagement can translate into measurable improvements in cardiovascular outcomes [ 23 ]. Psychological distress may affect cardiovascular outcomes through intertwined biological and behavioral pathways. Dysregulation of autonomic balance, heightened hypothalamic–pituitary–adrenal (HPA) axis activity, and low-grade systemic inflammation can adversely influence hemodynamics, metabolic profiles, and vascular function in patients with chronic heart disease. These physiological changes often coexist with behavioral factors such as reduced physical activity, poor dietary habits, and suboptimal medication adherence, all of which compound cardiovascular risk [ 2 , 9 , 24 ]. By enhancing emotional regulation, coping strategies, and health-related behaviors, structured psychological support may help interrupt these pathways and reinforce the benefits of routine cardiology care [ 25 , 26 ]. However, the association between HPA axis dysregulation and anxiety is not uniformly observed, with weaker or inconsistent correlations reported in disorders such as post-traumatic stress disorder and other anxiety-related conditions [ 27 ]. The autonomic nervous system—consisting of the sympathetic and parasympathetic branches—regulates key cardiovascular functions, including heart rhythm, blood pressure, and vascular tone [ 28 ]. These physiological alterations are believed to elevate the risk of developing CAD in affected individuals. Reduced heart rate variability (HRV) serves as an additional marker of autonomic imbalance and cardiovascular vulnerability [ 29 ]. Strengths and limitations This study offers valuable insights into the role of psychological support in the comprehensive management of CHD. However, several limitations should be considered when interpreting the findings. The primary limitation is the relatively short follow-up period of one year. Given the chronic nature of CHD, longer follow-up is needed to determine the sustainability of benefits and to assess long-term outcomes such as mortality and major cardiac events. Another limitation relates to the study population, which was drawn from outpatient cardiology clinics. These patients may receive more consistent medical attention than those in general or primary care settings, potentially limiting the generalizability of the results to broader CHD populations. Additionally, although randomization reduced selection bias, the open-label design may have introduced performance bias, as participants were aware of their group assignment—potentially influencing subjective outcomes such as quality of life and lifestyle behaviors. Despite using an intention-to-treat approach, loss to follow-up introduces the possibility of attrition bias. Moreover, the study relied on self-reported measures for lifestyle changes and medication adherence, which may be subject to reporting bias. Although outcome assessors were blinded, the intervention was necessarily open-label, and participants were aware of their group allocation. This awareness may have influenced self-reported outcomes, including quality of life, lifestyle behaviors, and medication adherence, through expectancy effects or social-desirability bias. However, objective outcomes such as lipid measurements, cardiac imaging parameters, blood pressure, and cardiovascular events were assessed by trained staff who were blinded to treatment allocation, which helps minimize the risk of measurement bias for the primary clinical endpoints. Another limitation relates to the duration of follow-up. Although a 12-month period provides important short-term evidence regarding the effectiveness of the intervention, it remains relatively brief for a chronic and progressive condition such as heart disease. Behavioral and psychosocial improvements may evolve or attenuate over longer periods, and the long-term sustainability of changes in cardiac function, lipid profile, and patient-reported outcomes cannot be fully assessed within the present timeframe. An extended follow-up period is planned to evaluate the durability of these effects beyond the first year of intervention. Future studies could enhance reliability by incorporating objective metrics such as pill counts, pharmacy records, or biomarker data to assess adherence and behavioral outcomes more accurately. Interpretation within the context of wider literature The findings of this study support and extend existing literature by demonstrating that integrating psychological support into cardiac care leads to significant improvements in lipid profiles, cardiac function, and HRQoL. While previous research has emphasized the psychosomatic interplay in cardiovascular health, this study provides empirical evidence across multiple health domains—highlighting the added value of a structured, multidisciplinary approach. These results reinforce prior work suggesting that addressing psychological well-being can enhance cardiovascular outcomes. Improvements observed in this study—such as enhanced cardiac performance and adherence, alongside better emotional and social functioning—align with the growing recognition that psychological distress contributes to disease progression and poor prognosis in CHD. Moreover, the discussion of underlying mechanisms, including reduced systemic inflammation and improved autonomic regulation, reflects established pathophysiological models linking mental health to cardiovascular risk. These findings contribute to a broader conversation in the literature advocating for the inclusion of mental health interventions as a core component of chronic disease management. Collectively, this study underscores the potential of psychologically-informed care models to enhance clinical and quality-of-life outcomes in patients with chronic heart disease. Implications for Policy, Practice, and research Policy: The findings support integrating psychological care into standard cardiac protocols. Reduced hospitalizations and cardiac events highlight potential cost savings, justifying policy-level incentives or mandates for multidisciplinary care models. Practice: A team-based approach—combining cardiology, psychology, nutrition, and physiotherapy—proved effective and scalable. Addressing psychological health should be a standard component of CHD management. Research: Further research is needed to evaluate long-term effects and identify the most impactful components of psychological interventions. This could optimize strategies for both efficacy and resource use. Conclusion In this randomized controlled trial, integrated psychological support delivered within a multidisciplinary cardiac care model was associated with improvements in lipid profile, cardiac imaging parameters, psychological wellbeing, medication adherence, and quality of life over 12 months. Although the intervention showed favourable trends in event-free survival, the relatively short duration of follow-up and small number of clinical events limit definitive conclusions regarding long-term outcomes. Overall, the findings suggest potential benefits of incorporating structured psychological support into routine cardiac care, while highlighting the need for extended follow-up to confirm the durability of these effects. Supplementary Information . Supplementary Material 1 (16.5KB, docx) Acknowledgements none. Author contributions YZ: Interpretation of data, drafting of the manuscript, Study concept and design; Final approval YL: Acquisition of data; drafting of the manuscript; Final approval HH: Acquisition of data; drafting of the manuscript; Final approval YX: Critical revision of the manuscript for important intellectual content; study supervision; Final approval. Funding None. Data availability The datasets generated and/or analyzed during this study are available from the corresponding author upon reasonable request. Declarations Consent to participate All participants were informed about the nature, purpose, potential risks, and benefits of the study. Written informed consent was obtained from each participant before enrollment. Participation was voluntary, and individuals were allowed to withdraw from the study at any point without any impact on their standard medical care. Competing interests The authors declare no competing interests. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Shepard D, VanderZanden A, Moran A, Naghavi M, Murray C, Roth G. Ischemic heart disease Worldwide, 1990 to 2013: estimates from the global burden of disease study 2013. Circ Cardiovasc Qual Outcomes. 2015;8:455–6. 10.1161/circoutcomes.115.002007. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Richards SH, Anderson L, Jenkinson CE, Whalley B, Rees K, Davies P, Bennett P, Liu Z, West R, Thompson DR. Psychological interventions for coronary heart disease: Cochrane systematic review and meta-analysis. Eur J Prev Cardiol. 2018;25:247–59. [ DOI ] [ PubMed ] [ Google Scholar ] 3. Nasiłowska-Barud A, Zapolski T, Barud M, Wysokiński A. Overt and Covert anxiety as a toxic factor in ischemic heart disease in women: the link between psychological factors and heart disease. Med Sci Monit. 2017;23:751–8. 10.12659/msm.902544. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 4. Correll MDEH, Bobes CU, Cetkovich-Bakmas J, Cohen M, Asai D, Detraux I, Gautam J, Möller S, Ndetei HJ, Newcomer DM, Uwakwe JW, Leucht R S. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care. World Psychiatry. 2011;10:52–77. 10.1002/j.2051-5545.2011.tb00014.x. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 5. Cairns M, Marais E, Joseph D, Essop MF. The role of chronic stress in the pathogenesis of ischemic heart disease in women. Compr Physiol. 2025;15:e70000. 10.1002/cph4.70000. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 6. Amare AT, Schubert KO, Klingler-Hoffmann M, Cohen-Woods S, Baune BT. The genetic overlap between mood disorders and cardiometabolic diseases: a systematic review of genome wide and candidate gene studies. Transl Psychiatry. 2017;7:e1007. 10.1038/tp.2016.261. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Whooley MA, Wong JM. Depression and cardiovascular disorders. Annu Rev Clin Psychol. 2013;9:327–54. 10.1146/annurev-clinpsy-050212-185526. [ DOI ] [ PubMed ] [ Google Scholar ] 8. Stapelberg NJ, Hamilton-Craig I, Neumann DL, Shum DH, McConnell H. Mind and heart: heart rate variability in major depressive disorder and coronary heart disease - a review and recommendations. Aust N Z J Psychiatry. 2012;46:946–57. 10.1177/0004867412444624. [ DOI ] [ PubMed ] [ Google Scholar ] 9. Tully PJ, Baumeister H. Collaborative care for comorbid depression and coronary heart disease: a systematic review and meta-analysis of randomised controlled trials. BMJ Open. 2015;5:e009128. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 10. Ski CF, Taylor RS, McGuigan K, Long L, Lambert JD, Richards SH, Thompson DR. Psychological interventions for depression and anxiety in patients with coronary heart disease, heart failure or atrial fibrillation. Cochrane Database of Systematic Reviews; 2024. [ DOI ] [ PMC free article ] [ PubMed ] 11. Lazzeroni D, Riccò L. (2023) The role of nurses in the multidisciplinary heart failure team: we are one but we are not the same. infermieristica journal 2. 12. Iovino P, Dollaku H, Alvaro R, Pucciarelli G, Rasero L, Macchi C, Liuzzi P, Riegel B, Vellone E. Sleep quality patterns in patients with heart failure: a person-centred latent class analysis from a secondary analysis of the MOTIVATE-HF trial. BMJ Open. 2025;15:e101950. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 13. Limonti F, Gigliotti A, Cecere L, Varvaro A, Bosco V, Mazzotta R, Gravante F, Ramacciati N. Evaluating the efficacy and impact of Home-Based cardiac telerehabilitation on Health-Related quality of life (HRQOL) in patients undergoing percutaneous coronary intervention (PCI): A systematic review. J Clin Med. 2025;14:4971. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 14. Dibben G, Faulkner J, Oldridge N, Rees K, Thompson DR, Zwisler AD, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2021;11:Cd001800. 10.1002/14651858.CD001800.pub4. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 15. Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, Franklin BA, Keteyian SJ, Kitzman DW, Regensteiner JG, Sanderson BK, Whooley MA. Home-Based cardiac rehabilitation: A scientific statement from the American association of cardiovascular and pulmonary Rehabilitation, the American heart association, and the American college of cardiology. J Am Coll Cardiol. 2019;74:133–53. 10.1016/j.jacc.2019.03.008. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 16. Feng J, Li S, Liu J. Nurse-led cardiac rehabilitation improves quality of life in elderly CAD patients: A retrospective cohort study. Med (Baltim). 2025;104:e44939. 10.1097/md.0000000000044939. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 17. Türen S, Çetinkaya Işık F, Türen S. The effect of cardiac rehabilitation program on quality of life, biophysiological parameters, and psychological features in patients with cardiovascular disease. Turkish J Cardiovasc Nurs. 2024;15:25–32. [ Google Scholar ] 18. Avila A, Claes J, Goetschalckx K, Buys R, Azzawi M, Vanhees L, Cornelissen V. Home-based rehabilitation with telemonitoring guidance for patients with coronary artery disease (short-term results of the trich study): randomized controlled trial. J Med Internet Res. 2018;20:e225. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 19. Hawkes AL, Atherton J, Taylor CB, Scuffham P, Eadie K, Miller NH, Oldenburg B. Randomised controlled trial of a secondary prevention program for myocardial infarction patients (‘ProActive Heart’): study protocol. BMC Cardiovasc Disord. 2009;9:16. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 20. Miller WR, Rollnick S. Motivational interviewing: helping people change. Guilford Press; 2012. 21. Rollnick S, Miller WR, Butler CC, Aloia MS. Motivational interviewing in health care: helping patients change behavior. Taylor & Francis; 2008. 22. Beck JS. Cognitive behavior therapy: basics and beyond. Guilford; 2020. 23. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis. JAMA Psychiatry. 2015;72:334–41. 10.1001/jamapsychiatry.2014.2502. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 24. Jiang Y, Shorey S, Seah B, Chan WX, San Tam WW, Wang W. The effectiveness of psychological interventions on self-care, psychological and health outcomes in patients with chronic heart failure—a systematic review and meta-analysis. Int J Nurs Stud. 2018;78:16–25. [ DOI ] [ PubMed ] [ Google Scholar ] 25. Vilchinsky N, Ginzburg K, Fait K, Foa EB. Cardiac-disease-induced PTSD (CDI-PTSD): A systematic review. Clin Psychol Rev. 2017;55:92–106. 10.1016/j.cpr.2017.04.009. [ DOI ] [ PubMed ] [ Google Scholar ] 26. Edmondson D, Rieckmann N, Shaffer JA, Schwartz JE, Burg MM, Davidson KW, Clemow L, Shimbo D, Kronish IM. Posttraumatic stress due to an acute coronary syndrome increases risk of 42-month major adverse cardiac events and all-cause mortality. J Psychiatr Res. 2011;45:1621–6. 10.1016/j.jpsychires.2011.07.004. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 27. Levine AB, Levine LM, Levine TB. Posttraumatic stress disorder and cardiometabolic disease. Cardiology. 2014;127:1–19. 10.1159/000354910. [ DOI ] [ PubMed ] [ Google Scholar ] 28. Edmondson D, Richardson S, Falzon L, Davidson KW, Mills MA, Neria Y. Posttraumatic stress disorder prevalence and risk of recurrence in acute coronary syndrome patients: a meta-analytic review. PLoS ONE. 2012;7:e38915. 10.1371/journal.pone.0038915. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 29. Marshe VS, Pira S, Mantere O, Bosche B, Looper KJ, Herrmann N, Müller DJ, Rej S. C-reactive protein and cardiovascular risk in bipolar disorder patients: A systematic review. Prog Neuropsychopharmacol Biol Psychiatry. 2017;79:442–51. 10.1016/j.pnpbp.2017.07.026. [ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1 (16.5KB, docx) Data Availability Statement The datasets generated and/or analyzed during this study are available from the corresponding author upon reasonable request. 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