The impact of COVID-19-related quarantine on psychological outcomes in patients after cardiac intervention: a multicenter longitudinal study

Italy’s first wave of COVID-19 in 2020 led to nearly two months of mandatory quarantine, which has been associated with increased depression, anxiety, eating disorders, and insomnia in the general population. Cardiac patients face higher COVID-19 complications and fatality risk and may have experienced additional psychological burden from isolation, with prior studies reporting elevated depressive and anxiety symptoms and poorer health-related quality of life during the pandemic. Psychological distress (depression, anxiety, insomnia) is bidirectionally linked with cardiac disease onset and mortality and commonly occurs after cardiac interventions, independently increasing morbidity and mortality. The added burden of quarantine in the critical 6–12 months post-intervention could exacerbate these symptoms, potentially undermining recovery, yet no study had directly evaluated quarantine effects in this population. This multicenter longitudinal study investigated whether experiencing COVID-19-related mandatory quarantine between six and 12 months after a cardiac intervention was associated with higher depressive, anxiety, and insomnia symptoms compared with a control group who completed assessments before the pandemic. The authors hypothesized higher symptoms in the quarantine-exposed group.

The introduction synthesizes evidence that COVID-19 quarantine increased psychological distress in the general population (depression, anxiety, insomnia) and in patients with chronic cardiovascular disease, with reports of worse health-related quality of life and heightened anxiety/depression. It highlights well-established links between post-intervention depression, anxiety, insomnia and increased cardiac morbidity and mortality, and notes that these symptoms typically decrease and stabilize 6–12 months after intervention. A key gap identified is the lack of studies examining the specific impact of COVID-19-related mandatory quarantine on psychological outcomes in cardiac patients after intervention.

Design: Multicenter longitudinal study with two time points: assessment approximately 1 month after cardiac intervention and reassessment approximately 8 months later (targeting the 6–12 month post-intervention window). Two groups were compared: a quarantine group (assessed before the COVID-19 outbreak and reassessed after experiencing mandatory quarantine) and a control group (both assessments completed before the outbreak). Setting and participants: Consecutive patients referred for cardiovascular examination after a cardiac intervention at the Unit of Cardiac Rehabilitation, ULSS 6 Euganea (Padua, Italy) or San Marco Hospital (Venice, Italy) from December 2017 to January 2020 were invited. Exclusion criteria: inability to read/understand Italian; visual/auditory impairments; conflicting research participation; life-threatening condition; history of severe psychiatric illness, symptomatic cerebrovascular disease, or neurological deficits (per medical records and staff). Ethics approvals were obtained; written informed consent was collected. Quarantine context: In Padua and Venice provinces, strict lockdown began March 8, 2020, restricting movement except for essentials; gradual easing began May 4, 2020. Control group reassessments occurred on site before Dec 3, 2019. Quarantine group reassessments were conducted via online forms (May 4–Sept 18, 2020) due to hospital restrictions. None of the quarantine group reported COVID-19 infection/positive tests during the study. Assessment procedures and measures: At assessment (∼28.28 days post-intervention on average), a trained psychologist administered a semi-structured interview and questionnaires in a quiet hospital room. Demographics (age, sex, education), intervention type [surgery: CABG, valve replacement/repair; procedure: PTCA], days since intervention, cardiac risk factors (hypertension, atrial fibrillation, diabetes, dyslipidemia), medications (β-blockers, antihypertensives, antiarrhythmics, anticoagulants, ACE inhibitors), walking minutes in the prior week were collected. SBP, DBP, BMI, and age-adjusted Charlson Comorbidity Index (CCI) were obtained from medical records. Psychological instruments: BDI-II (global and cognitive/somatic subscales; clinically relevant if >13), BAI (clinically relevant if >7), and SCI (DSM-5 compliant; putative insomnia if <16). At reassessment (mean 8.07 months after assessment), only BDI-II, BAI, and SCI were administered; by then, all patients had completed cardiac rehabilitation. Sample size and power: Power analysis (G*Power 3.1) assuming a small effect (η²=0.03) indicated 108 participants required for 80% power in a repeated-measures design; study sample met adequacy. Statistical analysis: Baseline comparisons between quarantine and control groups used Student’s t tests (continuous) and χ² tests (categorical). To assess selection bias, included vs non-included patients were compared on assessment variables. Mixed-effects repeated-measures models evaluated BDI-II, BAI, and SCI, adjusting for intervention type (surgery vs PTCA), CCI, and days since intervention, with fixed effects for time (assessment, reassessment), group (quarantine, control), and time×group interaction; subject was a random effect. Holm–Bonferroni correction was applied; significant interactions (p<0.05) were followed with Tukey post hoc tests. Clinically relevant caseness (depression, anxiety, insomnia thresholds) was compared by χ² at each time; when significant, logistic regression predicted caseness at reassessment, entering baseline caseness (block 1) and group (block 2). Analyses were conducted in R 3.6.1.

Sample and baseline: Final analyzed sample included 73 quarantine and 76 control patients. Groups did not differ at baseline in demographics, days since intervention, intervention type, cardiac risk factors (including CCI), medications, SBP/DBP, BMI, or walking time (all p>0.127). Included patients had slightly higher education than non-included (12.73 vs 11.00 years; t=3.67; p<0.001); no other differences survived correction. Depression (BDI-II): Significant time×group interaction for total BDI-II (β=2.52; 95% CI: 0.45–4.59; p=0.018; η²=0.04). Post hoc: quarantine group had higher depressive symptoms than controls at reassessment (p=0.005); no main time or group effects. BDI-II cognitive subscale showed a significant time×group interaction (β=1.55; 95% CI: 0.52–2.57; p=0.004; η²=0.06): quarantine group higher than controls at reassessment (p=0.003) and increased from assessment to reassessment (p<0.001). No effects for BDI-II somatic subscale. Clinically relevant depression: At assessment, 19% (14/73) vs 9% (7/76), χ²=2.29, p=0.130. At reassessment, 30% (22/73) vs 9% (7/76), χ²=9.11, p=0.002. Logistic regression predicting depression at reassessment: group (quarantine vs control) OR=4.20 (β=1.43; SE=0.55; Z=2.61; p=0.009) after controlling for baseline depression OR=20.18 (β=3.00; SE=0.59; Z=5.06; p<0.001); adding group increased explained variance by 5% (χ²=7.70, p=0.006). Anxiety (BAI): Significant time effect (β=−1.49; 95% CI: −2.79 to −0.18; p=0.027; η²=0.0005) and time×group interaction (β=2.71; 95% CI: 0.84–4.57; p=0.005; η²=0.05). Quarantine group had higher anxiety than controls at reassessment (p=0.004); no main group effect. Clinically relevant anxiety: at reassessment 53% (39/73) vs 38% (29/76), χ²=2.91, p=0.088 (ns). Sleep (SCI): Significant time effect (β=1.60; 95% CI: 0.31–2.90; p=0.016; η²=0.01) and time×group interaction (β=−2.04; 95% CI: −3.89 to −0.20; p=0.032; η²=0.03). Quarantine group had lower sleep quality than controls at reassessment (p=0.012); no main group effect. Clinically relevant insomnia: at reassessment 18% (13/73) vs 8% (6/76), χ²=2.46, p=0.117 (ns).

Findings support the hypothesis that experiencing mandatory quarantine during the COVID-19 pandemic adversely affected psychological outcomes in cardiac patients during the 6–12 month post-intervention period, when such symptoms typically stabilize or decline. Quarantine exposure was associated with higher overall depressive, anxiety, and insomnia symptoms at reassessment compared with controls, with a notable increase in cognitive depressive symptoms. Importantly, quarantine-exposed patients were 4.2 times more likely to meet criteria for clinically relevant depression at reassessment, independent of baseline depression. These results align with reports of worsened mental health in the general and chronic disease populations during quarantine and extend them to post–cardiac intervention patients. Given established links between depression, anxiety, insomnia and adverse cardiac outcomes (rehospitalization, mortality), the observed quarantine-related deterioration may undermine the benefits of cardiac rehabilitation and increase cardiac risk. The effects are unlikely due to direct SARS-CoV-2 illness since none reported infection, suggesting contributors such as social isolation/deprivation, health anxiety, intolerance of uncertainty, reduced access to care, and disruptions to cardiac rehabilitation delivery (e.g., temporary cessation, telehealth transitions). Integrating targeted mental health support within cardiac rehabilitation is warranted as the pandemic’s effects persist.

Mandatory quarantine after the COVID-19 outbreak in Italy was linked to higher depressive, anxiety, and insomnia symptoms in cardiac patients 8 months after cardiac intervention, a period when these symptoms typically stabilize. Given the association of these symptoms with poorer cardiac outcomes and higher mortality, the study underscores the need to integrate and enhance psychological assessments and interventions within cardiac rehabilitation programs. Future research should elucidate mechanisms underlying quarantine-related psychological deterioration and evaluate impacts on cardiovascular and functional outcomes (e.g., angina, restenosis, heart failure, return to work, quality of life).

- No healthy control group was included; differences from the general population cannot be determined. - Relatively small sample size limits generalizability and increases risk of false positives, although power analysis indicated adequacy for small effects and reporting was transparent. - Included patients had slightly higher education than non-included patients, which may introduce selection bias, though averages were comparable within the upper secondary education range. - No cardiovascular or functional outcomes were collected at reassessment, precluding assessment of downstream clinical impact.