Does Stress Management Improve Markers of Cardiovascular Disease?
abstract & commentary
By Ralph R. Hall, MD, FACP
Emeritus Professor of Medicine, University of Missouri, Kansas City School of Medicine
Disclosure; Dr. Hall is a consultant for Sanofi-Aventis.
Synopsis: Exercise and stress management improved markers of cardiovascular disease more than usual care alone.
Source: Blumenthal JA, et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease. JAMA. 2005;293:1626-1634.
This study was done because observational studies have shown that psychosocial factors are associated with increased risk for cardiovascular mortality and morbidity, but the effects of behavioral interventions on psychosocial and medical end points remain uncertain.
The objective of the study was to determine the effects of 2 behavioral programs, exercise and stress management, compared to routine medical care, on psychosocial functioning and markers of cardiovascular risk.
Subjects were randomized into 3 groups: 42 patients were randomized to usual care, 48 to usual care and exercise, 44 to usual care and stress management. The duration of the study for each patient was 16 weeks.
The outcome measures were measure of general distress (General Health Questionnaire [GHQ]) and depression (Beck Depression Inventory [BDI]), left ventricular ejection fraction (LVEF) and wall motion abnormalities (WMA), flow mediated dilation (FMD), and cardiac autonomic control (heart rate variability).
Patients in the exercise and stress management groups had the lowest BDI scores (exercise 8.2, stress management 8.2, usual care 10.1, (P = 0.02); reduced stress by GHQ scores and smaller reductions in LVEF during mental stress exercises. Exercise and stress management were associated with lower mean WMA rating scores (exercise 0.20, stress management 0.10 in a subset of patients with significant stress-induced WMA at baseline vs usual care 0.36; P = 0.02). Patients in the exercise and stress management groups had significantly greater mean improvements in FMD. In a subgroup, those receiving stress management showed improved baroreflex sensitivity vs usual care and significant increases in heart rate variability vs usual care.
Blumenthal and colleagues concluded that for patients with stable ischemic heart disease, exercise and stress management training reduced emotional distress and improved markers of cardiovascular risk more than usual medical care alone.
Commentary
This is a carefully blinded and conducted study (The staff that performed the testing was unaware of the patients’ group assignments). The usual care patients were monitored on a monthly basis to ensure they had not joined any exercise or stress management program.
Blumenthal et al note that the small size of the group and the absence of follow-up to determine the long-term clinical significance of improved ischemic activity are limitations of the study.
Additional limitations are that there are no data on risk factors such as blood pressure, blood lipids, and
markers such as C-Reactive Protein. Patients in group education sessions, ie, cardiac rehabilitation programs
etc, tend to reinforce each other’s compliance with regards to medications, attendance, and attitudes. It is
of note that only 77% of the usual care patients vs 89%
of the exercise training group attended 75% of the prescribed sessions.
The results then may be influenced by compliance with medication and the resulting decreases in blood pressure, blood lipids, and adherence to diet in those patients participating in the group sessions.
Previous studies have shown that treatment of depression and improved social support in patients with recent myocardial infarction have resulted in improvement in depression status and improved social support, but there was no influence morbidity or mortality.1
The improvements in wall motion, flow mediated blood flow, and heart rate variability are interesting and important, but we need to know what mechanisms are involved in the genesis of these improvements.
References
1. Berkman LF, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD). JAMA. 2003;289:3106-3116.
By Ralph R. Hall, MD, FACP Emeritus Professor of Medicine, University of Missouri, Kansas City School of Medicine Disclosure; Dr. Hall is a consultant for Sanofi-Aventis. Synopsis: Exercise and stress management improved markers of cardiovascular disease more than usual care alone.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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