JAMA. 2005;293(13):1626-1634.

Background

Observational studies have shown that psychosocial factors are associated with increased risk for cardiovascular morbidity and mortality, but the effects of behavioral interventions on psychosocial and medical endpoints remain uncertain.

Objective

To determine the effect of the addition of aerobic exercise training or stress management training to routine medical care on psychosocial functioning and markers of cardiovascular risk in patients with known ischemic heart disease (IHD).

Methods

134 patients with documented IHD and evidence of exercise-induced myocardial ischemia within the past year were enrolled. Patients underwent mental stress testing and a cycle ergometer exercise stress test. Gated equilibrium radionuclide ventriculography was performed prior to and during each of the stress tests to assess for segmental wall motion abnormalities. Flow-mediated dilation of the brachial artery, heart rate variability, and baroreflex sensitivity were also measured. Patients were then randomized to usual care, usual care plus supervised aerobic exercise training (35 minutes at 3 times per week), or usual care plus stress management training (1.5-hour weekly sessions). After 16 weeks, baseline measurements were repeated.

Results

124 (93%) patients completed the study. Improvement in treadmill duration was 19% for the exercise training group, 9% for the stress management arm, and 1% for the usual care group. Patients in the exercise and stress management training groups showed lower depression scores, reduced distress scores, smaller reductions in left ventricular function during mental stress testing, and lower mean wall motion abnormality scores compared with the usual care group. These groups also showed significant improvements in flow-mediated dilation of the brachial artery versus the control group. Only the stress management training group showed improvements in heart rate variability and baroreflex sensitivity when compared with the usual care group.

Conclusion

This study showed that behavioral treatments provide added benefits to routine medical care in patients with ischemic heart disease. Patients who underwent 4 months of either aerobic exercise or stress management training showed improvements in psychosocial functioning, less emotional distress, lower levels of depression, and improved markers of cardiovascular risk. This the first study to demonstrate favorable effects of stress reduction on vascular endothelial function.

Comments

This study was not designed to evaluate the effects of exercise or stress management on morbidity and mortality, and improvements in the cardiovascular markers studied may not necessarily translate to reduced clinical events. Nevertheless, this study adds to the body of evidence regarding the beneficial effects of exercise and stress reduction in patients with IHD. Perhaps, future studies could look at the effects of alternative exercise regimen that also target stress reduction, such as yoga, Pilates, and tai chi. These alternative exercise regimens may be more attractive to some of our elderly, obese, or more debilitated patients.-ST