Randomized Controlled Trial of Cognitive Behavioral Therapy vs Standard Treatment to Prevent Recurrent Cardiovascular Events in Patients With Coronary Heart Disease: Secondary Prevention in Uppsala Primary Health Care Project (SUPRIM)

Study Questions:

Does cognitive behavioral therapy (CBT) have an impact on recurrent cardiovascular disease (CVD) events following hospital discharge from a coronary heart disease (CHD) event?


This randomized study recruited consecutive patients from 1996 through 2002 that were discharged from Uppsala Hospital 3-12 months following an index CHD event (acute myocardial infarction [AMI], percutaneous coronary intervention [PCI], or coronary artery bypass grafting [CABG]). Eligibility included men and women ages 75 years or younger who lived in the primary care catchment area and who could be discharged to the primary care physician within 1 year. A total of 362 patients were randomized to receive traditional care (reference group, 170 patients) or traditional care plus a CBT program (intervention group, 192 patients), that included 20 two-hour sessions during 1 year, focused on stress management. Follow-up data collection was completed in 2008. Outcome variables were all-cause mortality, hospital admission for recurrent CVD, and recurrent AMI.


A total of 71% of eligible patients participated. Of the 362 patients, there were 85 women (23.5%) and 277 men (76.5%); mean age was 62 years, 77% were married, 51.1% had been admitted for an AMI, 33.7% for a CABG, and 15.2% for a PCI. Over 50% in each group were either old-age or disability pensioners. Median attendance at each CBT session was 85%. Recurrent CVD events occurred in about 50% of the reference group by 108 months. During a mean 94 months of follow-up, the intervention group had a 41% lower rate of fatal and nonfatal first recurrent CVD events (hazard ratio [95% confidence interval], 0.59 [0.42-0.83]; p = 0.002), 45% fewer recurrent AMIs (0.55 [0.36-0.85]; p = 0.007), and a nonsignificant 28% lower all-cause mortality (0.72 [0.40-1.30]; p = 0.28) than the reference group after adjustment for other outcome-affecting variables. In the CBT group, there was a strong dose-response effect between intervention group attendance and outcome. During the first 2 years of follow-up, there were no significant group differences in traditional risk factors.


A CBT intervention program decreases the risk of recurrent CVD and recurrent AMI. This may have implications for secondary preventive programs in patients with CHD.


Psychosocial factors are independently associated with increased risk of CVD morbidity and mortality, but the effects of psychosocial factor intervention on CVD are inconclusive. The Uppsala study had five key components with specific goals: education, self-monitoring, skills training, cognitive restructuring, and spiritual development—and was focused on stress management, coping with stress, and reducing experience of daily stress, time urgency, and hostility. Most previous studies failed to show a value of CBT for reducing recurrent CVD events. The authors suggest that to affect CVD or CHD endpoints, the interventions need to be long-term (possibly 6-12 months), be conducted in groups, and include specific techniques for altering behavior and psychophysiologic stress response. The reproducibility of the outstanding results in other patient populations needs to be evaluated.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Prevention

Keywords: Reproducibility of Results, Myocardial Infarction, Follow-Up Studies, Secondary Prevention, Coronary Disease, Risk Factors, Cognitive Therapy, Primary Health Care, Percutaneous Coronary Intervention

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