Psychological couple-oriented interventions for patients with heart disease and their partners: a scoping review and guidelines for future interventions

Objective This scoping review aims to provide an accessible summary of available evidence on the efficacy of psychological couple-based interventions among patients with heart disease and their partners focusing on specific aspects and strategies by assessing different emotional and physical cardiac-related outcome measures. Methods A literature search was performed in PubMed, Scopus, Medline, PsycINFO, and Web of Science databases using the keywords “heart diseases” and “couple-based intervention.” A literature search using systematic methods was applied. Data were extracted to address the review aims and were presented as a narrative synthesis. Results The database search produced 11 studies. Psychological couple-based interventions varied in terms of the type of intervention, personnel, format (group or individual, phone or in person), number of sessions, and duration. Most of the contributions also lacked adequate details on the training of professionals, the contents of the interventions, and the theoretical models on which they were based. Finally, although partners were involved in all the treatment, in most studies, the psychological strategies and outcomes were focused on the patient. Conclusion The variability of the psychological couple-based interventions of included studies represents a challenge in summarizing the existing literature. Regarding their impact, psychological interventions for patients with cardiovascular disease and their partners were found to moderately improve patients’ and partners’ outcomes.


Introduction
Having a heart disease redefines oneself as ill, modifies one's significant bonds, and requires constant lifestyle changes according to the disease progression (Roger et al., 2020).Furthermore, the management of heart disease is complex and requires constant monitoring of symptoms over time.For this reason, if present, the partner plays an important role by providing both practical and emotional support (Bertoni et al., 2015;Donato et al., 2020).Since romantic relationships play a significant role in people's lives (Bertoni et al., 2015), it is important to investigate the role of the partner in either helping or hindering the patient's psychological adjustment to heart disease over the course of the medical treatment.
The role of the partner in cardiovascular disease is central from the acute to the chronic phase of the illness, commonly faced at home (Rapelli et al., 2022).During hospitalization, the presence of a supportive partner can make a difference in terms of the patient's recovery and psychological wellbeing.By supporting patients' self-efficacy (Maeda et al., 2013;Rapelli et al., 2022), partners might increase their ability to self-care (George-Levi et al., 2016;Rapelli et al., 2021) even in complex medical situations when an implantable device like the left ventricular assist device is needed (LVAD; Golan et al., 2023;Rapelli et al., 2023).In addition, partners might help to reduce patients' symptoms of depression and/or anxiety (Sokoreli et al., 2016;Bouchard et al., 2019;Rapelli et al., 2021) or monitor their compliance to complex pharmaceutical therapies, make appointments for follow-ups and accompany the patient to the visits, detect signs of cardiac symptomatology, and be the primary person responsible for the patient's hyposodic diet (Randall et al., 2009;Rapelli et al., 2020a).
A supportive partner also motivates and helps the patient adopt healthier lifestyle habits-thus reducing cardiovascular risk factors (Maeda et al., 2013;Rapelli et al., 2022) and rates of participation in cardiac rehabilitation programs (Rankin-Esquer et al., 2000).
Conversely, not all forms of support are helpful (Breuer et al., 2017).Indeed, studies have shown that social support may be split into positive and negative forms.Cardiac patients have been the subject of substantial research on positive support, defined as interactions that foster affection (Sebri et al., 2021).On the other hand, scholars paid less attention to negative support, or when the beneficiary of support regards it as unhelpful or feels social limitations by others (Breuer et al., 2017).In fact, patients who feel poorly emotionally supported experience a 41% higher risk of non-compliance with the treatment than those who feel supported by their partner (Leifheit-Limson et al., 2012).Furthermore, perceiving the partner as hostile or overprotective could hinder the patients' motivation or become a barrier to behavioral changes, thus affecting their health (Fiske et al., 1991;Rapelli et al., 2020b;Bertoni et al., 2022).
Still, partners are not immune to the sense of emptiness and lack of control commonly caused by the disease (Rapelli et al., 2020a), and providing support may be a very stressful and demanding experience for informal caregivers, i.e., those who provide unpaid care to their loved ones (Randall et al., 2009;Bertoni et al., 2015;Rapelli et al., 2020a).
Healthy spouses might present high levels of distress (Randall et al., 2009;Bertoni et al., 2015;Rapelli et al., 2020a) and posttraumatic stress symptoms (Vilchinsky et al., 2017;Fait et al., 2018).Furthermore, partners may refer to absent relational and sexual satisfaction (Bouchard et al., 2019) and perceived low positive dyadic coping, which represents a risk factor for the provision of inadequate support (Rapelli et al., 2021).In addition, it has been speculated that the ability of the spouses of patients with heart disease to be supportive decreases over time, while critical and controlling behaviors increase (Stephens et al., 2006;Rapelli et al., 2022) in the presence of caregiver burden (Luttik et al., 2007).
Since coping with cardiac problems represents, therefore, a dyadic experience rather than proper of the patients (e.g., Rapelli et al., 2021Rapelli et al., , 2022Rapelli et al., , 2023;;Golan and Vilchinsky, 2023), there is a growing demand for couple-based interventions for heart disease that focus not only on the patients but also on their partners.
For these reasons, this scoping review aims to provide an overview of available evidence on couple-based psychological interventions for coping with heart disease involving both patient and partner by answering the following research questions: (1) What are the main characteristics in terms of the theoretical model, provider, and format of intervention?(2) Which psychological strategies are specifically used in the intervention?(3) Which scoping review outcomes are measured in the short-and longterm?

Methods
In the present study, the results of a scoping review focused on couple-based interventions for patients with heart diseases and their partners are shown.Data extraction, critical appraisal, and qualitative synthesis were in line with established systematic review and qualitative synthesis methods (Khan et al., 2003).

Search strategy
Searches were conducted in PubMed, Scopus, Medline, PsycINFO, and Web of Science from November to December 2022.
The search strategies combined key terms and Medical Search Headings (MESH) terms based on the PICO (Patient/Population, Intervention, Comparison, and Outcomes) framework as follows: ("CVD" OR "Cardiovascular disease" OR "Cardiac") AND ("Couple" OR "Dyad" OR "Partner" OR "Caregiver") AND ("Couple-based intervention" OR "Couple therapy" OR "Couple program") (Huang et al., 2006).Boolean and truncation operators were used to systematically combine more searched terms and list documents containing variations on search terms, respectively.The search syntax was modified as appropriate for each database.were included.Records were excluded if they (1) considered only biomedical outcome variables, (2) were review articles, singlecase studies, mixed-method studies, protocol studies, workplace interventions, theses, or internal reports of gray literature, (3) involved only the patient or their family members as caregivers (e.g., parents, siblings, cousins, etc.).Unpublished works were not considered.No restrictions were set for the date of publication and type of study design.

Study selection
Following the search and exclusion of duplicates, two reviewers (authors GR and CT) independently assessed the eligibility of the articles first on the title and the abstract, and the full text according to the inclusion criteria.Author 3 (CT) resolved disagreements.Following Smith et al. (2011) recommendation, the review team included two people with methodological expertise in conducting systematic reviews (EG and GP) and at least two experts on the topic under review (GR and CT).The reference lists of all selected articles and relevant systematic reviews were manually screened to identify any further references for possible inclusion-but none was found.
A search of electronic databases identified 222 reports, of which 165 were excluded based on information from the title and abstract after removing duplicates.The remaining 23 articles were evaluated for inclusion by reviewing their full text, which resulted in the 10. 3389/fpsyg.2023.1194767exclusion of 11 records.The flowchart presented in Figure 1 provides step-by-step details of the study selection.
They discussed any discrepancies, and, if necessary, consulted a third author (EG) to reach a final decision (Table 1).Extracted data were collated to produce a narrative summary of couple-based interventions for cardiac patients and their partners.Furthermore, to report all characteristics of studies and interventions the CONsolidated Standards of Reporting Trials 2010 checklist (Consort10; Schulz et al., 2010) and the Template for Intervention Description and Replication checklist (TIDieR;Hoffmann et al., 2014) were used.

Description of intervention
The main characteristics of the interventions were extensively reported in Supplementary material 1 using the CONsolidated Standards of Reporting Trials 2010 checklist (Consort10; Schulz et al., 2010)  In all the selected studies, the treatment aimed at providing heart disease-related information to both patients and their informal caregivers-with the main aim to address treatment expectations, and ambivalence toward behavioral change, as well as to define goals and increase the patient-partner dyad's adherence to treatment recommendations.
The intervention was delivered through regular in-person focus group meetings in 6 out of 11 studies (Dracup et al., 1984;Lenz and Perkins, 2000;Stewart et al., 2001;Daugherty et al., 2002;Sher et al., 2014;Tulloch et al., 2021).The number of intervention sessions ranged from one (Daugherty et al., 2002) to 18 (Sher et al., 2014).In particular, in the study by Daugherty et al. (2002) the intervention group (IG) consisted in talking about the benefits of social support and of the importance of making lifestyle changes together as partners to modify ineffective behaviors (i.e., criticism and overprotection) using discussion and role-playing.In the study by Dracup et al. (1984), the impact of 10 individual sessions with patients only was compared with a couple-based intervention of equal length.In both IGs, a counseling program on problemsolving was delivered.
In the study by Lenz and Perkins (2000), only partners participated in the focus groups, alternated by telephone sessions.In the study by Sher et al. (2014), couples-assisted focus training groups on behavioral change were provided.In the study by Stewart et al. (2001) patients and partners support group interventions were delivered.In the study by Tulloch et al. (2021), patients and partners participated in an in-person group focused on disease management.
Four interventions out of 11 (Gortner et al., 1988;Thompson, 1989;Johnston et al., 1999;Hartford et al., 2002) were inperson individual/(couple) education programs followed by weekly telephone support sessions provided by nurses for 7 (Hartford et al., 2002) or 8 weeks (Gortner et al., 1988).The number of in-person sessions ranged from one (Gortner et al., 1988) to 6 (Hartford et al., 2002).Specifically, the intervention delivered in the study by Gortner et al. (1988) focused on promoting self-efficacy, emotional distress, increased physical activity, and adherence to diet among patients.In the study by Hartford et al. (2002) Frontiers No CG Both patients and partners express that the Active Heart site is a useful tool for educating patients in the rehabilitation process and that it provides relevant information about heart disease, symptoms, and lifestyle changes.Then, telerehabilitation gives them an overview of goals, plans, and appointments, creating a greater sense of coherence in the rehabilitation process and fostering patient autonomy because they feel more involved in making personal decisions about the rehabilitation process.The partners evaluate the telematic rehabilitation plan as very useful to facilitate understanding and consistency in the rehabilitation process for both themselves and the patient, thus creating a greater feeling of safety.Some partners, however, take on too many responsibilities during their participation in the rehabilitation program and find it difficult to orient themselves between the desire to be involved, to be overprotective toward the patient and at the same time remain an equal partner in the rehabilitation process.It turns out that partners have become an important support resource in everyday life for patients, motivating them to continue changes in their training lifestyle alone.Many patients report a lack of sense of belonging to a therapeutic community.

TAU
Counseling intervention, based on the symbolic interactionism approach, reports greater positive effects on the compliance of the heart risk factors: smoking, blood pressure, body weight, and weekly exercise.In particular, smoking has not changed over time, in fact, the behavior related to smoking has not been significantly different over time between groups for both patients and partners.The experimental groups have significantly lower blood pressure recorded at 6 months in the follow-up.The largest decrease is in IG2.The results show a significant difference between the groups in body weight: in fact, both IG1 and IG2 obtained and maintain long-term weight loss compared to the TAU, in which body weight increases in the follow-up by 6 months.Patients in IG1 have greater compliance on cardiac risk factors, but participation in a cardiac rehabilitation program is not, in itself, sufficient to influence long-term compliance.Then, by results, the role of family members may have an enabling or inhibiting effect on patient compliance; they may or may not apply a reason for complying with a specific system of conduct.IG > CG for self-efficacy in the lifting of objects at 3 months (t = 2.19, p = 0,034), and CG > IG for tolerance of stress and anger (emotional distress) at 3 months (t = 2.90, p = 0,007).No significant differences between groups for partners.At 6-months follow-up the differences are not, statistically significant.There were not significant differences on POMS and significant differences between groups for partners.For the family functioning APGAR, FIRM, and MAS no significant differences were observed between patients and partners of IG and those of CG at 3and 6-months follow-ups.People over the age of 70 have a higher perception of self-efficacy effort and report significantly lower levels of hostility and depression compared to those in their 50 s.With regard to family functioning and family resources, there are not significant differences in measures between groups; however, the partners report lower levels compared to patients. (Continued)
[correct, F(4,98) = 10.35,p = 0.0005; misconceptions, F(4,98) = 4.01, p = 0.005; uncertainty, F(3.2,78.8)= 5.28, p = 0.002].On depression, patients and partners of IG1 had lower levels than the CG at 6 months; whereas the IG2 has lower levels than the CG at 2-and 6-months follow-up [Patients: F(5.9,256.6)= 3.43, p = 0.003]; Partners: [F(5.7,134.3)= 3.08 g, p = 0.008].On anxiety, patients and partners of IG1 had lower scores than the CG at discharge, and at 2 months and the IG2 had lower levels than the CG at 2-, 6-, and 12-months follow-ups (Patients: [F(7.0,302.7)= 2.32 g, p = 0.03]; Partners: [F(5.7,133.1) 5 2.28, p = 0.043].The IG2 has lower anxiety than IG1 at 2-and 6-months follow-up.On satisfaction with care IG1 and IG2 have higher levels than CG.For satisfaction with care patients and partners of IGs showed higher levels of it compared with CG at 2-months follow-up (Patients: [F(2,85)  No significant differences between groups for patients regarding CES-D (F1,34 = 0.01, p < 0.91).COOP (overall: F1,36 = 0.09, p < 0.67; physical: F1,35 = 0.24, p < 0.63; emotional: F1,36 = 0.24, p < 0.63).On satisfaction with nursing care patients of IG reported higher levels than the CG at 3-months follow-up, but not significantly (F1,35 = 1.87, p < 0.18).For partners, there was no significant difference between IG and CG, for COOP (F1,31 = 0.62, p = 0.44) and depression, but their depressive symptoms decreased over time (F1,32 = 0.48, p = 0.49).IG has significantly higher YPAS level than CG at 18-month follow-up (B = −0.06[95% CI: −0.119 to −0.001], p = 0.043, d = 0.82; large effect size).There is also an interaction between marital satisfaction and treatment condition: patients in CG who reported higher levels of marital distress did not maintain their physical activity gains by the end of treatment, while both distressed and non-distressed patients in IG exhibited accelerating gains throughout treatment.There are no significant changes in medication adherence across groups (B = −0.021[95% CI: −0.393 to 0.351], p = 0.27), but patients in CG showed a 9% relative decrease across time.There is an interaction between baseline marital satisfaction and treatment condition: patients in CG who reported lower levels of initial marital satisfaction showed deterioration in marital satisfaction, while non-satisfied patients in IG showed improvement over time [B = 0.0002 (95% CI: 0.0004 to 0), p = 0.050].There were no significant effects for nutritional outcomes and weight loss variables (such as BMI) across time or between treatment conditions.The social comparison gives benefits to the group: couples normalize their experience and felt understood and reassured.The couple perceives the group as a safe place to expose their experiences and where they could learn.Information support has reduced uncertainty in couples about the activities to be followed in rehabilitation; emotional support has reassured and given hope to couples.
The intervention also greatly improves communication, understanding, and acceptance within the couple; it promotes better lifestyle adaptation and a change in coping strategies to make the stressful situation worse; it increases the couple's sense of control and marital quality. (Continued)

TAU
The mean scores for patient anxiety in the IG were statistically significantly decreased in comparison to the CG (P < 0.0005), as were the mean scores for patient depression (P = 0.01).The mean scores for partner anxiety in the IG were statistically significantly decreased in comparison to the CG (P = O.O1), but the difference in mean scores for depression in partners was not statistically significant (P > 0.10).Social support (Cobb, 1976); emotional theory (Cobb, 1976).

Psychoeducational
Couples assist focus group meetings and individual interviews aimed to talk about the benefits of social support and the importance of making lifestyle changes together, to modify ineffective behaviors, like criticism and overprotection (role-playing session and discussion about expectations and the importance of self-monitoring) and to decrease barriers  (Bowlby, 1969(Bowlby, , 1973) ) Psychoeducational In-person group with couples.Participants are guided through seven conversations, based on EFT principles, in which they learn to communicate their need for connection and reassurance.The focus is on CVD and healthy coping together.Partners become adept at recognizing problematic relationship patterns and rectifying them through a series of structured conversations that involve identifying the impact of CVD on their relationship, acknowledging their fears and longings in the aftermath of CVD, healing emotional injuries, and discussing their sexuality in light of their health.
Frontiers in Psychology 10.3389/fpsyg.2023.1194767 the intervention consisted of information and support to assist patients and partners in meeting their needs.Johnston et al.
One intervention was conducted online (Dinesen et al., 2019) and focused on self-management, physical activity, nutritional counseling, and adherence to medications, besides providing psychosocial support.
3.3.1.2.The psychological strategies used in the intervention Only 2 out of the 11 contributions detailed the psychological strategies employed in the intervention (Stewart et al., 2001;Tulloch et al., 2021).In particular, in the study by Stewart et al. (2001) the topics changed weekly based on experienced common stressors.Group discussions were enriched by varied techniques and resources depending on the topic (e.g., case study scenarios focused on a couple coping with a recent myocardial infarction (MI), role-plays, invited consultant or guest speakers, focus group discussions, guided group exercises-for example, weekly diaries about the perceived importance of a given topic, etc.).In the study by Tulloch et al. (2021), couples were guided through seven conversations in which they learned to communicate their need for connection and reassurance, recognize problematic relationship patterns, and rectify them through a series of structured conversations facilitated by different therapeutic strategies including (a) recognize and name emotional states (known as "symbolization"), (b) engage in direct expressions of vulnerability and need ("enactments"), and (c) respond to clear manifestations of vulnerability and a desire for connection ("empathic attunement through enactment").

The provider of the intervention
The majority of the psychological interventions were provided by one or more trained nurses in 7 interventions (Dracup et al., 1984;Gortner et al., 1988;Thompson, 1989;Johnston et al., 1999;Lenz and Perkins, 2000;Daugherty et al., 2002;Hartford et al., 2002); while in two studies to lead the intervention was a therapist or clinical psychologists (Sher et al., 2014;Tulloch et al., 2021), and in the study by Dinesen et al. (2019) a nurse and a professional with psychological background.Only in one study (Stewart et al., 2001), professionals from various disciplines all working regularly with persons with cardiac disease and/or community-based client groups, and peer supporters (couples in which one spouse was at least 1-year post-MI) conducted the intervention.

Control group
Four studies compared the IG with the treatment-as-usual (TAU) condition (Dracup et al., 1984;Thompson, 1989;Johnston et al., 1999;Hartford et al., 2002).Furthermore, educational counseling group or individual sessions focused on increasing awareness of the benefits of a healthy lifestyle were used as controls in three contributions (Gortner et al., 1988;Lenz and Perkins, 2000;Sher et al., 2014), while four records did not include any control groups (CGs) (Stewart et al., 2001;Daugherty et al., 2002;Dinesen et al., 2019;Tulloch et al., 2021).

Study duration
Study duration ranged from 2 months (Hartford et al., 2002;Tulloch et al., 2021) to 18 months (Sher et al., 2014).In three studies the intervention had a total duration of 3 months (Lenz and Perkins, 2000;Stewart et al., 2001;Dinesen et al., 2019), in three studies the intervention had a total duration of 6 months (Dracup et al., 1984;Gortner et al., 1988;Thompson, 1989), and only in one study the intervention had a total duration of 12 months (Johnston et al., 1999).

Outcomes
Significant and non-significant effects for both patients and partners are reported in Figure 2. Furthermore, in Supplementary material 2 an extensive summary of the primary and secondary outcomes of the included studies is presented.Briefly, this scoping review showed that couple-based interventions that involved both patients and partners focused on individual outcomes only, relational outcomes only, or both.One out of the 11 selected studies focused on patient individual outcomes only (Sher et al., 2014) not considering partner individual and relational outcomes.Four out of 11 studies focused on patient and partner individual outcomes (Dracup et al., 1984;Thompson, 1989;Johnston et al., 1999;Hartford et al., 2002).Three out of 11 studies focused on patient individual and relational outcomes (Gortner et al., 1988;Sher et al., 2014;Tulloch et al., 2021).Two studies out of 11 focused on patient and partner individual and relational outcomes (Gortner et al., 1988;Tulloch et al., 2021).
Regarding the partner's primary outcomes: anxiety was measured in 4 studies (Thompson, 1989;Johnston et al., 1999;Hartford et al., 2002;Tulloch et al., 2021), satisfaction with care was measured in 3 studies (Johnston et al., 1999;Daugherty et al., 2002;Dinesen et al., 2019), depression was measured in 2 studies (Johnston et al., 1999;Tulloch et al., 2021), mood states were measured in one study (Gortner et al., 1988), quality of life was measured in one study (Tulloch et al., 2021), disease knowledge was measured in one study (Johnston et al., 1999).In 4 studies (Gortner et al., 1988;Stewart et al., 2001;Daugherty et al., 2002;Tulloch et al., 2021) the primary outcome pertained to marital functioning.In particular, social support was the primary outcome in the qualitative interview studies of Stewart et al. (2001) and Daugherty et al. (2002).In the study by Gortner et al. (1988) family functioning was quantitatively assessed.Last, relationship quality and couple satisfaction were measured in the study by Tulloch et al. (2021).
Regarding the secondary outcomes, in the study by Sher et al. (2014) patient marital satisfaction was measured.One study assessed (Lenz and Perkins, 2000) the level of the partner's physical status.One study assessed (Lenz and Perkins, 2000) the level of partner depression.Both patient and partner satisfaction with care was also assessed in one study (Tulloch et al., 2021).

Effects of the intervention across time-points
Results from 5 out of the 11 included studies showed that couple-based interventions were more effective than TAU and/or educational programs in increasing patient outcomes.In particular, self-efficacy at 3-month follow-up (Gortner et al., 1988), disease knowledge at 12-month follow-up (Johnston et al., 1999), physical activity at 18-month follow-up (Sher et al., 2014), satisfaction with care (Johnston et al., 1999;Lenz and Perkins, 2000) at 2-and 3-month follow-ups, respectively.Results from 4 out of the 11 included studies showed that couple-based interventions were more effective than TAU and/or educational programs in decreasing patient anxiety at 5-days from discharge (Thompson, 1989), and at 1- (Thompson, 1989), 3-(Thompson, 1989), 6-(Thompson, 1989), 12-month (Johnston et al., 1999) follow-ups.Furthermore, significant decreases in patient depression at 3month follow-up (Thompson, 1989), blood pressure at 6-month follow-up (Dracup et al., 1984), and patient-perceived disability at 12-month follow-ups (Johnston et al., 1999) were observed.Regarding the 4 interventions that did not include a CG, only the study by Tulloch et al. (2021) had a quantitative approach and showed a significant increase in the quality of life and dyadic adjustment of the patients, and a significant decrease in their partners' depression, dyadic adjustment, and couple satisfaction at a 2-month follow-up.
Results from 1 out of the 11 included studies showed that couple-based interventions were more effective than TAU and/or educational programs in increasing partner satisfaction with care at Frontiers in Psychology 13 frontiersin.org2-month follow-up (Johnston et al., 1999) and disease knowledge at 12-month follow-up (Johnston et al., 1999).A significant decrease in the partner's anxiety is observed at 5 days from discharge (Thompson, 1989), 3-(Thompson, 1989), 6-(Thompson, 1989), and 12 months (Hartford et al., 2002) follow-ups.No significant differences were found for depressive or anxiety symptoms at the 6-month follow-up (Dracup et al., 1984), and for physical exercise level (Sher et al., 2014); there was a significant effect of couple treatment on the increased physical activity and acceleration of treatment over time, but there were no condition effects for adherence to medications and nutritional outcomes.
Notably, significant between-group differences favoring couple-based interventions were mostly observed in the short term, and results were not always maintained over time.

Discussion
This paper explores the existing literature on couple-based interventions for cardiac patients.
Although evidence increasingly supports the dyadic influence that coping with cardiac illness has on cardiac patients and their partners (Cook and Kenny, 2005), findings reveal that couplebased interventions have received little attention in the literature.Moreover, psychological interventions widely vary in terms of the type of intervention, format (group or individual, phone or in person), number of sessions and duration, and personnel involved across the selected records.In addition, the psychological strategies of the interventions are mostly not comprehensively detailed.This makes it difficult to explore which of them had a specific impact on the dyad's outcomes and prevent effective studies' replication.Most of the contributions also lack adequate details on the training of the providers, the contents of the interventions, and the theoretical models on which they were based.
Moreover, we could not assume that couple-based interventions are more or less effective than individual ones, since only 2 out of the 11 studies included in this review (Dracup et al., 1984;Sher et al., 2014) compared a couple-based approach with a patient-only approach.
Regarding the type of intervention, two different types of couple-based interventions can be distinguished.The first class of interventions can be labeled as "partner-assisted"-since the partner acts as the patient's therapist or coach.These interventions often follow a cognitive-behavioral framework, and require specific tasks to be completed outside the treatment sessions.The treatment plan is supported by the couple's relationship -but does not focus on it-and does not imply the presence of relational difficulties.This type of couple-based intervention is used in 6 out of the 11 included studies (Dracup et al., 1984;Thompson, 1989;Johnston et al., 1999;Daugherty et al., 2002;Hartford et al., 2002;Dinesen et al., 2019).
A second group of couple interventions-used in 5 out of 11 studies (Gortner et al., 1988;Lenz and Perkins, 2000;Stewart et al., 2001;Sher et al., 2014;Tulloch et al., 2021)-focuses on how a couple interacts in scenarios associated with the individual's disease.These "disorder-specific" interventions consider the couple's relationships as a variable potentially affecting either the disorder or the treatment.
No study included in this review implemented couple therapy used with the intent of assisting the individual during the treatment based on the assumption that the functioning of the couple contributes in a broad sense to the development or maintenance of their symptoms.
Overall, couple-based interventions have been shown to have only a modest impact on patients' outcomes including quality of life, psychological distress, level of physical activity, blood pressure, self-efficacy, disease knowledge, satisfaction with care, and dyadic adjustment.
Partners showed improved perceived psychological distress, disease knowledge, and satisfaction with care; and increased dyadic adjustment scores and couple satisfaction at the relational level.
However, although partners are involved in the treatment, the strategies and the outcomes of the studies are mostly focused on the patient.In fact, as previously mentioned also in other studies (e.g., Rapelli et al., 2022Rapelli et al., , 2023)), it is recommended that relational variables be targeted for interventions.
These findings coupled with those of previous systematic reviews documenting the benefit of couple interventions for patients with chronic diseases (Hartmann et al., 2010;Martire et al., 2010) including cardiac illness (Reid et al., 2013).
However, our results need to be interpreted with caution due to the limitations of the included studies.
This review has some limitations, among them not having considered the assessment of methodological quality, but this limitation is pertinent to the objectives of the scoping review and the heterogeneity of the included studies.Furthermore, it is also worth noting that it was decided to exclude gray literature from the study.This may have affected the validity of the study, but gray literature is not usually subjected to a rigorous review process.
As a strength, we can recognize the use of the TIDieR and Consort10 checklists as useful tools for the replicability of studies since they provide a summary of the proposed interventions with an examination of the limitations and criticalities of the studies themselves.In fact, the present scoping review offers significant information that may guide the design of future research and interventions aimed at improving the efficacy and effectiveness of couple-based interventions for cardiac patients.Specifically, we reported guidelines for research and interventions in the next section.

Future research and clinical directions
For future research, given the limitations of the included studies and in order to determine which psychological interventions are most effective, a large, adequately powered, trial assessing psychological interventions for patients alone, compared with psychological interventions for patients and partners, could be recommended.A variety of variables might be investigated, including the timing of the intervention's start, its intensity, and duration, while also taking into account a clear definition of intervention, its form of delivery, its content, and the type, education, and experience of the therapist.Furthermore, other information lacking in the included studies was the attrition rate and factors related to participation/non-participation.In fact, according to a recent study (Savioni et al., 2022)  consideration participants' reasons for non-participation/dropout that often are linked to factors related to intervention commitment and its interference with daily life.From a clinical point of view, according to the results of this scoping review, more interventions targeted at relational variables are needed.This also means involving the partner in the treatment to increase knowledge of reciprocal needs and activate dyadic resources.The partner would become more aware of the treatment process, more conscious about individual and relational aspects that can influence the patient and the couple's relationship, and consequently, more involved in the engagement process (Graffigna et al., 2017).Moreover, behavioral modification programs may benefit both the targeted and the non-targeted member of the couple by reducing cardiovascular risk factors in both partners through a virtuous process so one motivates the other since often partners share the same unhealthy diet and inadequate physical activity of patients (Shiffman et al., 2020).
In addition, in the context of chronic illness, it is demonstrated that a group format facilitates the expression and sharing of emotions of both members of the dyad (Saita et al., 2014(Saita et al., , 2016) ) and is cheaper in terms of time and resources compared with individual sessions (Saita et al., 2014).
The use of digital tools might also ensure greater adherence to behavioral changes and support the emotional state of both patients and their partners outside the clinical settings (Graffigna et al., 2017;Dinesen et al., 2019;Bertuzzi et al., 2022).Specifically, telemedicine could be useful to assess caregivers' burden and to offer specific psychological support to those partners who experience adverse outcomes (Semonella et al., 2022(Semonella et al., , 2023)).

Conclusion
The available literature on couple-based intervention for cardiac patients is scarce and inconsistent, and mostly focused on the outcomes of the sufferers.More research also considering the dyadic component of the intervention and the specific effect of a given program on informal caregivers is urgently needed.Indeed, in the context of chronic diseases, a fundamental role in supporting the patients is played by their informal caregivers, i.e., those who provide unpaid care to their loved ones (Rapelli et al., 2022(Rapelli et al., , 2023;;Semonella et al., 2023).
Caring for a significant other can be a rewarding experience, but due to a lack of time and energy, or financial, emotional, and social strains, it can also turn out to be an overwhelming responsibility for caregivers (Donato et al., 2020;Rapelli et al., 2020a;Bertuzzi et al., 2021).Therefore, it is important to ensure the wellbeing of partners of individuals with cardiovascular disease, and adequately support them with tailored and integrated healthcare actions within the context of cardiac rehabilitation and through the use of telemedicine.

TABLE 1 (
Continued) The group is based on couple-level discussions of the day's topic as well as practice time for the communication skills being taught.Therapists served as a source for the couples' discussion, observing and making suggestions for the content of the discussion as well as the process.The relationship content in the couples intervention instructed and encouraged patients and their partners to collaborate on making behavioral and relationship changes.
future psychological interventions may employ ad hoc tools to take into