UNC Health Talk

Adding stress management to cardiac rehab cuts new heart incidents in half

Patients recovering from heart attacks or other heart trouble could cut their risk of another heart incident by half if they incorporate stress management into their treatment, according to research from Duke Health and UNC Health Care.

The findings, published March 21 in the American Heart Association journal Circulation, are the result of a randomized clinical trial of 151 outpatients with coronary heart disease who were enrolled in cardiac rehabilitation due to heart blockages, chest pain, heart attacks, or bypass surgery. They ranged in age from 36 to 84 years old.

About half of the patients participated in three months of traditional cardiac rehabilitation, which included exercise, a heart-healthy diet, and medications to manage cholesterol and high blood pressure.

Patients were followed for an average of three years after rehab.

The other half went to cardiac rehab and also attended weekly, 90-minute stress management group meetings that combined support, cognitive behavior therapy, muscle relaxation, and other techniques to reduce stress. Patients were followed for an average of three years after rehab.

Thirty-three percent of patients who received only cardiac rehabilitation had another cardiovascular event such as a heart attack, bypass surgery, stroke, hospitalization for chest pain or death from any cause. By comparison, 18 percent of the patients who participated in stress-management training during their cardiac rehabilitation had subsequent cardiovascular trouble – about half the rate of the other group.

Both sets of patients that went to rehab fared better still than recovering heart patients who elected not to attend rehab; 47 percent of the latter group later died or had another cardiovascular incident, according to the article.

Reducing stress may seem like an obvious part of any plan for improving heart health, said lead author James Blumenthal, PhD, a clinical psychologist and professor in psychiatry and behavioral sciences at Duke.

“Over the past 20 to 30 years, there has been an accumulation of evidence that stress is associated with worse health outcomes.”

“Over the past 20 to 30 years, there has been an accumulation of evidence that stress is associated with worse health outcomes,” Blumenthal said. “If you ask patients what was responsible for their heart attacks, most patients will indicate that stress was a contributing factor.” But stress management is typically not part of most cardiac rehabilitation programs, he said.

“I think part of the issue is that stress is hard to define, and there’s no universally accepted way of measuring it or treating it,” Blumenthal said. “The data we provide indicate that by reducing stress, patients can improve clinical outcomes, even beyond the benefits that we know exercise already has on reducing stress and improving cardiovascular health.”

For the trial, patients’ stress levels were measured using five standard instruments on which participants self-reported their levels of depression, anxiety, anger, and perceived stress. Overall, those who participated in stress management reported reductions in anxiety, distress, and their overall level of perceived stress.

Both groups that participated in cardiac rehabilitation saw similar and significant physical improvements in their cholesterol levels and proteins that indicate heart disease-related inflammation, as well as their exercise capacity.

“We have known for some time that participation in a supervised exercise program is beneficial in patients with coronary heart disease,” said Alan Hinderliter, MD, associate professor of medicine in the division of cardiology at the UNC School of Medicine and co-investigator on the trial. “The results of this study suggest that stress management is also a very important element of a comprehensive cardiac rehabilitation program. The intervention was clearly helpful in reducing stress levels, but we need additional research to confirm the benefits of stress management in improving cardiovascular outcomes.”

Although death rates from heart disease have improved, it remains the number one cause of death in the United States and is growing worldwide, according to the American Heart Association.

Dr. Hinderliter is a member of the McAllister Heart Institute and the UNC Center for Heart and Vascular Care.

In addition to Blumenthal and Hinderliter, study authors included Andrew Sherwood, PhD; Patrick J. Smith PhD; Lana Watkins PhD; Stephanie Mabe; William E. Kraus, MD; Krista Ingle, PhD; and Paula Miller, MD.

The National Heart, Lung, and Blood Institute, a component of the National Institutes of Health, supported this study.