The Benefits of Stress Management in Heart Disease Patients

Takeaway Points:

1. Psychosocial factors have been linked to an increased risk for cardiovascular disease (CVD) morbidity and mortality; however, the effects of psychosocial factor intervention on CVD are uncertain.
2. Psychosocial factors that may promote atherosclerosis and CVD belong to two general categories: chronic stressors and emotional factors, both of which are believed to contribute to the risk of heart disease.
3. Patients who participated in a cognitive behavioral therapy intervention focusing on stress management exhibited a 41% lower rate of cardiovascular events than those in the traditional care group.
4. CBT interventions that are long-term, are conducted in groups, and include specific techniques for altering behavior can yield positive outcomes for cardiovascular disease patients.

A cognitive behavioral therapy program focusing on stress management appears to decrease the risk of recurrent heart attacks and other cardiovascular events in patients with heart disease, according to research published in the Archives of Internal Medicine.

Although it has been established in previous studies that psychosocial factors are independently associated with increased risk of cardiovascular disease (CVD) morbidity and mortality and account for an estimated 30% of heart attack risk, the effects of psychosocial factor intervention on CVD are uncertain.

“Psychosocial factors that may promote atherosclerosis and cardiovascular disease belong to two general categories: chronic stressors, including low socioeconomic status, low social support, marital distress and work distress; and emotional factors, including major depression, hostility, anger and anxiety,” the authors wrote. These issues are believed to contribute to the risk of heart disease even after adjusting for the effects of traditional risk factors.

Mats Gulliksson, MD, PhD, and colleagues at Uppsala University Hospital in Uppsala, Sweden, conducted a randomized controlled clinical trial of cognitive behavioral therapy (CBT) to measure its effects on CVD recurrence. Subjects included 362 men and women discharged from the hospital after a coronary heart disease event within the previous 12 months; of those patients, 192 patients were randomly assigned to participate in CBT.

"The program has five key components with specific goals—education, self-monitoring, skills training, cognitive restructuring and spiritual development—and is focused on stress management, coping with stress and reducing experience of daily stress, time urgency and hostility," the authors wrote. Therapy was delivered in 20 two-hour sessions during one year, in small groups separated by sex. The other 170 patients received traditional care.

During an average 94 months of follow-up, 23 participants in the CBT group died, 69 (35.9%) had a non-fatal cardiovascular event, and 41 (21.4%) had a non-fatal heart attack. In the traditional care group, there were 25 deaths, 77 non-fatal cardiovascular events (45.3%), and 51 non-fatal heart attacks (30%) Patients in the CBT group had a 41% lower rate of both fatal and non-fatal heart events, 45% fewer recurrent heart attacks, and a non-significantly lower rate of death (28%) than those in the traditional care group. Attending a higher proportion of the therapy sessions was associated with a further reduction in risk, according to Gulliksson and colleagues.

“These results imply that, to affect cardiovascular disease or coronary heart disease end points, the interventions need to be long-term (possibly six to 12 months), be conducted in groups and include specific techniques for altering behavior," they wrote. “A possible mechanism is decreased behavioral and emotional reactivity, which would lead to less psychophysiologic burden on the cardiovascular system.”

The findings represent not only statistical significance but also clinical importance, the authors noted, concluded that “this demonstrates the potential efficacy of adding CBT to secondary preventive programs after acute myocardial infarction [heart attack] for better patient adherence to treatment and better outcome.”