Cardiac rehabilitation plus stress management training may improve outcomes

For patients with coronary heart disease, cardiac rehabilitation with stress management training may lead to reductions in cardiac events, anxiety, distress and perceived stress, according to a randomized trial.

Lead researcher Joseph A. Blumenthal, PhD, of the Duke University Medical Center, and colleagues published their results online in Circulation on March 21.

“Cardiac rehabilitation programs do not routinely offer stress management, but this may change should demand increase,” Blumenthal said in a news release. “And because patients may be reluctant to ask for the programs themselves, the onus is on the physicians to recognize that stress management is important for the optimal medical management of patients.”

The researchers mentioned that cardiac rehabilitation is common for patients with coronary heart disease and typically consists of physical exercise, medical management of elevated blood pressure and lipids, nutritional counseling and smoking cessation. However, stress management training is not usually included as part of cardiac rehabilitation.

In this study, the researchers randomized 151 outpatients with stable coronary heart disease to comprehensive cardiac rehabilitation or comprehensive cardiac rehabilitation plus stress management training. The patients had recent acute coronary syndrome or stable angina with angiographic evidence of coronary disease or underwent CABG or PCI.

The cardiac rehabilitation sessions took place at Duke University’s Center for Living and the University of North Carolina’s Wellness Center in Chapel Hill. As part of the program, patients engaged in aerobic exercise three times per week for 35 minutes at a level of 70 percent to 85 percent of their heart rate. They also received education about coronary heart disease and nutritional counseling and had two classes on the role of stress in coronary heart disease.

Patients who were assigned to the stress management training underwent 12 weekly sessions with four to eight participants that lasted 90 minutes apiece. At the end of the 12-week program, all patients were re-assessed and followed for a median of 3.2 years.

To measure psychological stress, which was the primary outcome, the researchers used the following measures: Beck Depression Inventory II, State-Trait Anxiety Inventory, Patient-Reported Outcomes Measurement Information System Anger, General Health Questionnaire and Perceived Stress Scale.

They also used exercise treadmill testing, accelerometry and leisure-time physical activity to measure exercise tolerance and physical activity. In addition, they measured blood lipids.

Of the patients, 18 percent in the cardiac rehabilitation plus stress management training group, 33 percent in the cardiac rehabilitation group and 47 percent in a matched sample of patients who did not receive cardiac rehabilitation had clinical events. The researchers defined clinical events as any of the following: all-cause mortality, fatal and nonfatal MI, coronary or peripheral artery revascularization, stroke/transient ischemic attack and unstable angina requiring hospitalization.

The patients undergoing cardiac rehabilitation plus stress management training also had reductions in symptoms of anxiety, depression and stress compared to the group that only received cardiac rehabilitation.

The results of this study differed from findings from a British study that found cardiac rehabilitation had no effect on mortality and did not reduce patients’ stress levels. However, the researchers mentioned patients in the British study only had cardiac rehabilitation once per week for six to 10 weeks.

The researchers mentioned a few limitations of the study, including that they had a small sample size and they observed a small percentage of death and nonfatal MI. They added that a multi-site effectiveness trial was necessary to confirm the findings to a larger population of patients receiving cardiac rehabilitation.