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Effects on Prognosis and Evaluation of Mechanisms

James A. Blumenthal, PhD; Wei Jiang, MD; Michael A. Babyak, PhD; David S. Krantz, PhD; David J. Frid, MD; R. Edward Coleman, MD; Robert Waugh, MD; Michael Hanson, MD; Mark Appelbaum, PhD; Christopher O'Connor, MD; James J. Morris, MD

Arch Intern Med. 1997;157(19):2213-2223.

Abstract
Background
Previous studies have demonstrated that myocardial ischemia can be elicited by mental stress in the laboratory and during daily life and that ischemia induced by mental stress is associated with an increased risk for future cardiac events in patients with coronary artery disease.

Objectives
To examine the extent to which ischemia induced by mental stress can be modified by exercise or stress management, and to evaluate the impact of these interventions on clinical outcomes.

Methods
One hundred seven patients with coronary artery disease and ischemia documented during mental stress testing or ambulatory electrocardiographic monitoring were randomly assigned to a 4-month program of exercise or stress management training. Patients living at a distance from the facility formed a nonrandom, usual care comparison group. Myocardial ischemia was reassessed following treatment, and patients were contacted annually for as long as 5 years to document cardiac events, including death, nonfatal myocardial infarction, and cardiac revascularization procedures.

Results
Twenty-two patients (21%) experienced at least 1 cardiac event during a mean (±SD) follow-up period of 38 ± 17 months. Stress management was associated with a relative risk of 0.26 compared with controls. The relative risk for the exercise group also was lower than that of controls, but the effect did not reach statistical significance. Stress management also was associated with reduced ischemia induced by mental stress and ambulatory ischemia.

Conclusion
These data suggest that behavioral interventions offer additional benefit over and above usual medical care in cardiac patients with evidence of myocardial ischemia.

Arch Intern Med. 1997;157:2213-2223

Author Affiliations
From the Departments of Psychiatry and Behavioral Sciences (Drs Blumenthal and Babyak), Medicine (Drs Jiang, Waugh, O'Connor, and Morris), and Radiology (Drs Coleman and Hanson), Duke University Medical Center, Durham, NC; the Department of Medical and Clinical Psychology, the Uniformed Services University of the Health Sciences, Bethesda, Md (Dr Krantz); the Department of Medicine, Ohio State University, Columbus (Dr Frid); and the Department of Psychology, University of California, San Diego (Dr Appelbaum).

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