Stress management program helps prevent heart events in patients with heart disease

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 a report in the January 24 issue of Archives of Internal Medicine.

Psychosocial factors account for an estimated 30 percent of heart attack risk, according to background information in the article. "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 write. These issues are believed to contribute to the risk of heart disease even after adjusting for the effects of traditional risk factors.

Mats Gulliksson, M.D., Ph.D., and colleagues at Uppsala University Hospital, Uppsala, Sweden, conducted a randomized controlled clinical trial of cognitive behavioral therapy (CBT) among 362 men and women discharged from the hospital after a coronary heart disease event within the previous 12 months. A group of 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 write. 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 percent) had a non-fatal cardiovascular event and 41 (21.4 percent) had a non-fatal heart attack. This compares to 25 deaths, 77 non-fatal cardiovascular events (45.3 percent) and 51 non-fatal heart attacks (30 percent) in the traditional care group. Patients in the CBT group had a 41 percent lower rate of both fatal and non-fatal heart events, 45 percent fewer recurrent heart attacks and a non-significantly lower rate of death (28 percent) than patients in the traditional care group. Attending a higher proportion of the therapy sessions was associated with a further reduction in risk.

"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," the authors write. "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 note. "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," they conclude.