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To assess the relationship between changes in health-related quality of life (HRQOL) and initial levels of distress in cardiac patients who received multidisciplinary cardiac rehabilitation (CR) or usual care. High rates of psychological distress have been reported in cardiac patients.Cardiac patients completed a questionnaire battery at the start and finish of a CR program (n = 131) or at equivalent times after hospital discharge in comparison hospitals where CR was not available (n = 185). The questionnaire battery comprised the Hospital Anxiety and Depression Scale, the Health Complaints Scale, and the Quality of Life Index Cardiac Version III (QLI CV-III).Significant correlations between initial levels and subsequent changes in distress and HRQOL measures were found for both the CR and comparison groups. The CR program was associated with significant changes in both somatic and cognitive complaints for only those in distress. Changes in functional and psychological morbidity were greater in the CR group than in the comparison group.Changes in HRQOL were significantly related to the initial levels of distress found in cardiac patients, regardless of CR attendance. The CR program had beneficial effects on levels of functional ability and on psychological morbidity reduction. Implications of the research for CR outcomes assessment are considered.