To our knowledge, this systematic review is the first that aimed to summarize the evidence regarding the impact of psychoeducational rehabilitation in patients with ACS. More specifically, the provided data are clearly promising in terms of the utility of these interventions to improve hard endpoints as well as the quality of life, including alleviation of symptoms of depression and anxiety. Taking into account the heterogeneity issue of the included studies, we emphasize the need for large RCTs with structured integrated multi-modality psychological interventions with a detailed methodology of implementation. By presenting in detail the interventions used in the included randomized controlled trials (type of psychotherapy, number of sessions, and total dose performed) and thus by exposing their heterogeneity, we propose a personalized medicine approach in the psychoeducational rehabilitation of ACS. The benefits of psychoeducational interventions on different aspects of cardiac rehabilitation programs are illustrated in .
Most studies in the field enrolled patients without a determination of various mental health comorbidities with ACS before the intervention. The literature presents a minority of trials that divided the intervention group into two subgroups: with and without comorbidity. We did not find any RCT that studied the benefits of a psychoeducational intervention applied only to patients without a mental disorder diagnosed with ACS. This is an important area for future research, taking into account a substantial increase in the prevalence of mental health disorders among patients with acute MI, according to Sreenivasan et al. [
49]. Particularly for depression, a multifaceted and bidirectional relationship with cardiovascular disease is described, especially with ACS [
50]. Thus, depression by itself may be the cause of MI, but it is not known whether psychoeducation in this category of patients has similar benefits to the same intervention in patients without depressive symptoms. Meta-analyses in this field have demonstrated the benefit of psychological intervention on mortality and morbidity in CAD [
11,
23,
24,
25,
26,
27]. The latest update of the most rigorous reviews (by Cochrane Collaboration) [
25] showed the benefit in the current era of optimal psychoeducational intervention. Regarding prognostic outcomes, the positive clinical outcome that resulted from the analysis was for cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). In contrast, no obvious effect was demonstrated in terms of risk reduction for total mortality (RR 0.90, 95% CI 0.77 to 1.05), rates of revascularization (RR 0.94, 95% CI 0.81 to 1.11), and rates of non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05). The meta-analysis has revealed a reduction in depressive symptoms (SMD −0.27, 95% CI −0.39 to −0.15), anxiety (SMD −0.24, 95% CI −0.38 to −0.09), and stress (SMD −0.56, 95% CI −0.88 to −0.24) in the intervention group compared to the comparator group. In addition, by direct comparison of the studies, the authors demonstrated positive effects on health-related quality of life, type A behavior, and vital exhaustion. Moreover, the systematic review of Reid et al. [
11] completes the data from the literature and shows the benefits of psychological intervention on blood pressure for patients. Furthermore, the authors describe a positive effect on knowledge and satisfaction for both patients and their partners. As demonstrated in the Cochrane review [
22], education-based intervention in CAD reduced fatal and/or non-fatal cardiovascular events (other than MI) compared to control groups receiving no education (RR 0.36, 95% CI 0.23 to 0.56). Regarding the health-related quality of life, the heterogeneity of measures applied in the studies included in this meta-analysis made it impossible to find consistent evidence. However, there is limited information regarding the improvement of some domain scores. There was no difference in the outcomes for total mortality, fatal and/or non-fatal MI, total revascularizations, and hospitalizations.