Exercise and Stress Management Training on Markers of Cardiovascular Risk in Patients with Ischemic Heart Disease
Exercise and Stress Management Training on Markers of Cardiovascular Risk in Patients with Ischemic Heart Disease
By Sarah L. Berga, MD
James Robert McCord Professor and Chair,
Department of Gynecology and Obstetrics,
Emory University School of Medicine, Atlanta.
Dr. Berga is a consultant for Pfizer, Organon, and Women First, Inc., and is involved in research for Berlex and Health Decisions, Inc.
Source: Blumenthal JA, et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: A randomized controlled trial. JAMA 2005;293:1626-1634.
Blumenthal and colleagues point out in the introduction that psychological factors are recognized to play a significant and independent role in the development of ischemic heart disease and its complications, but it is not clear if psychological or behavioral interventions will reverse established cardiac conditions. They undertook the present study to test the hypothesis that stress reduction would lead to better cardiovascular health in individuals with established ischemic heart disease. Subjects were randomized to one of three arms: usual care, usual care plus an exercise program, and usual care plus cognitive behavior therapy ([CBT], stress management). Participants were 92 men and 42 women between the ages of 40 and 84 years with stable ischemic heart disease and exercise-induced myocardial ischemia. Subjects were followed for 16 weeks and monitored before and after the three arms. After the intervention, patients in the exercise and stress-management arms had lower mean Beck Depression Index scores, reduced distress as measured by the General Health Questionnaire, and better left ventricular ejection fractions during mental stress testing. In those with abnormal cardiac wall motion, stress management led to greater reduction than exercise, but both exercise and stress management were better than usual care alone. This is the first study to show that stress reduction reduces cardiovascular risk in patients with ischemic heart disease partly through favorable effects on vascular endothelial function. The study was too small and too short, however, to determine if these improvements would reduce future clinical events or improve long-term survival.
Comments
It is often, but not universally, accepted that appropriate psychological care improves mental health at least some of the time. The concept that better mental health leads to better general health has not been as widely endorsed by the medical establishment or insurance providers, although certain lay groups and individuals believe that meditation and related psychological interventions can be used to treat conditions such as hypertension or irritable bowel syndrome. In particular, skepticism remains regarding the impact on psychological interventions upon core physiological dysfunctions that lead to medical diseases. However, we recently showed that CBT designed to ameliorate problematic attitudes and behaviors reversed functional hypothalamic amenorrhea, often now termed stress-induced anovulation, in a majority of women willing to undergo 16 weeks of intervention with a trained psychologist or social worker. Since we previously found that functional hypothalamic amenorrhea was associated with elevated circulating cortisol levels, a measure of stress or psychological arousal, we were not so surprised to find that, in addition to allowing return of central GnRH drive and ovulatory ovarian function, CBT also reduced cortisol levels.1 Although the present study did not investigate directly all the possible mechanisms by which CBT improved cardiovascular measures in patients with ischemic heart disease, one cannot help but wonder if these patients had a reduction in circulating cortisol or other measures of physiological arousal.
Stress takes a toll upon the body in many ways and it is not clear why its manifestations are so variable, but it may be that stress finds our unique psychological and physiological vulnerabilities. Although CBT needs to be targeted to an individual’s specific problematic attitudes and behaviors, it appears that some form of CBT might benefit many conditions that are linked to or exacerbated by stress. In this paper, Blumenthal et al define stress as "an imbalance between excessive demands and inadequate coping skills." The universal goal of any type of CBT is to teach the patient better attitudes, which included in this study "monitoring irrational thoughts and generating alternative interpretations of situations or unrealistic thought patterns." Patients were "instructed in progressive muscle relaxation and imagery techniques, along with training in assertiveness, problem-solving, and time management." Indeed, since feeling overwhelmed is the sine qua non of stress, the objective of CBT is to restore the locus of control to the individual. I like to say that society may reward great achievement (often made possible by obsessive overwork) but the endocrine system rewards behavioral moderation. Most of us could benefit from learning to better manage problematic attitudes and behaviors, but it would appear that there are some individuals whose life or fertility may depend upon it. The hurdle now is for us to learn to recognize those who are most in need of CBT as an adjunct to the treatment established life-threatening medical conditions.
Reference
1. Berga SL, et al. Recovery of ovarian activity in women with functional hypothalamic amenorrhea who were treated with cognitive behavior therapy. Fertil Steril 2003;80:976-981.
James Robert McCord Professor and Chair, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta. Dr. Berga is a consultant for Pfizer, Organon, and Women First, Inc., and is involved in research for Berlex and Health Decisions, Inc. Source: Blumenthal JA, et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: A randomized controlled trial. JAMA 2005;293:1626-1634.Subscribe Now for Access
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