Enhancing Cardiac Rehab With Stress Management Training

Study Questions:

High stress is associated with higher mortality and nonfatal events in coronary heart disease (CHD), but does stress management training (SMT) improve outcome in cardiac rehabilitation (CR)?


A total of 151 outpatients with CHD, aged 36-84 years, were randomized to 12 weeks of comprehensive CR or comprehensive CR combined with SMT (CR+SMT) (1.5 hours weekly education, group support, and cognitive behavior therapy) with assessments of global stress (combination of depression, anxiety, anger, general distress, and perceived stress), and CHD biomarkers obtained before and after treatment. A matched sample of CR-eligible patients who did not receive CR comprised a No-CR comparison group. All participants were followed for up to 5.3 years (median = 3.2 years) for clinical cardiovascular events.


Mean age was about 60 years, 36% were female, and about 34% were on psychotropic medication. Indications for CR were revascularization in 63%. Patients randomized to CR+SMT exhibited greater reductions in composite stress levels compared with those randomized to CR alone (p = 0.022), an effect that was driven primarily by improvements in anxiety, distress, and perceived stress. Both CR groups achieved significant, and comparable, improvements in CHD biomarkers. Participants in the CR+SMT group exhibited lower rates of clinical events compared with CR alone (18% vs. 33%; hazard ratio [HR], 0.49 [0.25, 0.95]; p = 0.035) and both CR groups had lower event rates compared to the No-CR group (47%; HR, 0.44 [0.27, 0.71]; p < 0.001).


CR enhanced by SMT produced significant reductions in stress and greater improvements in medical outcomes compared with standard CR. These findings indicate that SMT may provide incremental benefit when combined with comprehensive C,R and suggest that SMT should be incorporated routinely into CR.


This is a very difficult and important controlled study that is the first to show a clinical benefit from a comprehensive nonpharmacologic psychological intervention integrated into cardiac rehab. The intervention is costly and to what degree patients would be willing and compliant in the ‘real world’ is not known. Patients were not selected based on initial ‘stress’ profile and patients with greater stress had more improvement. Until larger trials are available, good clinical practice would include assessing for psychological distress in all patients, and inclusion of education regarding stress/depression/anger as a standard. Additionally, there should be consideration of referral to an experienced social worker or psychologist for those with high scores. Our experience is that patients are more willing to attend if the psychological distress is obtained by testing and the behavioral therapist is on-site.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Stress

Keywords: Anger, Anxiety, Biological Markers, Cognitive Therapy, Coronary Artery Disease, Depression, Exercise Test, Myocardial Revascularization, Outcome Assessment (Health Care), Primary Prevention, Rehabilitation, Stress, Psychological

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