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Medical memo: Stress and the heart: Treatment helps

Medical memo

Stress and the heart: Treatment helps

America’s epidemic of coronary artery disease began to gather steam in the early part of the 20th century. By 1921, heart disease had become the nation’s leading killer, but it took scientists awhile to catch on. By now, though, doctors have learned that smoking, abnormal cholesterol levels, high blood pressure, diabetes, obesity, and lack of exercise all contribute to cardiac risk. Even more important, they’ve learned that corrective measures can reduce risk. This important knowledge has contributed to a 56% decline in heart disease deaths and a 70% drop in stroke fatalities over the past 50 years.

Physicians have long suspected that psychological factors also contribute to cardiac risk. Because emotions are harder to measure than cholesterol, blood pressure, and body fat, it’s been harder to prove. That started to change in 1959, when Dr. Meyer Friedman and Dr. Ray Rosenman reported that the “Type A” personality was a strong predictor of cardiac risk. There followed a flurry of research that didn’t always agree with the original findings. Still, the new investigations put psychological influences firmly on the list of cardiac risk factors. Most studies agree that even if the Type A hypothesis has not lived up to its billing, its major components — anger, hostility, and stress — are each important. Research also suggests that social isolation and depression may be even stronger risk factors, particularly for men.

Identifying risk factors is always useful, but the proof is in the demonstration that treatment helps. Dr. Friedman argued that special Type A counseling could do just that, but many cardiologists remained skeptical. However, research from Duke University suggests that stress reduction really can reduce cardiac events in men.

The subjects were 94 patients with coronary artery disease and clear-cut evidence of myocardialischemia, an insufficient supply of oxygen-rich blood to the heart muscle. The volunteers were randomly assigned to receive standard medical care or to get the same care supplemented by four months of aerobic exercise or four months of stress-reducing psychological treatment. The exercise program consisted of 45-minute sessions three times a week for 16 weeks. The stress management program consisted of 90-minute group sessions conducted weekly for the same period.

At the start of the trial, each patient underwent a detailed evaluation for myocardial ischemia that consisted of 24-hour EKG monitoring as well as exercise- and mental-stress testing using heart scans and EKGs to detect ischemia. The researchers tracked the patients for five years, evaluating clinical events and medical costs.

All in all, stress management proved effective. The patients who received counseling experienced an average of 0.8 additional cardiac events over five years while the patients who got standard care averaged 1.4 events. The stress-reduction patients also ran up smaller average medical bills than the standard care group ($9,251 vs. $14,997). The patients who exercised came out between the other groups, but statistical tests could not distinguish their results from those of the others.

It’s a small study, and more research is needed to find out which patients benefit most from stress-reducing treatment. It is also important to compare various psychotherapeutic techniques with medications for anxiety and depression. Still, the Duke research adds another link to the connection between emotional health and cardiac disease. When it comes to the heart, the mind matters.

Last updated:	August 21, 2006