National guidelines recommend that patients with coronary heart disease (CHD) be referred to cardiac rehabilitation (CR), in which patients receive education and counseling on physical exercise, blood pressure and lipid management, nutrition, and smoking cessation. “Mounting evidence suggests that elevated stress is associated with a greater risk of death and non-fatal cardiac events in CHD patients, but stress management training (SMT) is not yet routinely included as a component of most CR programs,” says James A. Blumenthal, PhD. Currently, there is a lack of consensus about how stress is defined and measured and uncertainty about the most effective SMT approaches to improve outcomes in patients with CHD.

Evaluating Potential Benefits

For a study published in Circulation, Dr. Blumenthal and colleagues evaluated the potential incremental benefits of SMT when combined with comprehensive CR on psychological stress and CHD biomarkers of risk. “Our analysis also examined the impact of CR alone or in combination with SMT as compared with patients who were eligible for CR but elected not to participate in such a program,” Dr. Blumenthal adds. The investigators then assessed rates of adverse clinical events over a follow-up period of up to 5.3 years.

The study, which included 151 outpatients with CHD aged 36 to 84, randomized participants to 12 weeks of comprehensive CR or comprehensive CR combined with SMT (CR+SMT). The SMT intervention included a 1.5-hour weekly meeting of small groups (four to eight patients) in which participants were educated about the effects of stress on the heart and were taught skills for coping effectively with everyday stressors. Patients also received group support from the other participants. The study team also trained patients on methods to reduce stress, such as relaxation techniques, recognizing maladaptive thought patterns, and managing time effectively.

“Patients receiving CR+SMT had greater reductions in stress levels when compared with those randomized to CR alone,” says Dr. Blumenthal. “Both CR groups achieved significant improvements in CHD biomarkers, but the CR+SMT had lower rates of clinical events than those receiving only CR.” Dr. Blumenthal notes that patients with greater stress levels at baseline tended to exhibit even larger improvements than those with lower levels. He adds, however, that stress levels also decreased among patients receiving CR alone, but not to the extent of those receiving CR+SMT. Both CR groups also displayed better health outcomes compared to patients who elected not to engage in CR.

Assessing Implications

“Our data suggest that SMT could benefit all cardiac patients similarly to how exercise training is encouraged in CR regardless of patients’ level of physical fitness,” Dr. Blumenthal says. “SMT should be considered when developing comprehensive CR programs because it can improve medical outcomes and quality of life by lowering stress levels, which is a health benefit in and of itself.”

When compared with usual care, several other randomized controlled trials have previously reported no benefit with SMT in reducing stress and improving clinical outcomes. The study from Dr. Blumenthal and colleagues highlights the need for more research into the effectiveness and applicability of using SMT in a larger CR population. A multisite effectiveness trial is needed to confirm the study results.

James A. Blumenthal, PhD, has indicated to Physician’s Weekly that he has no financial disclosures to report


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