Coronary heart disease patients saw 50% fewer cardiac events

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Coronary heart disease patients saw 50% fewer cardiac events

Post by freckles1880 » March 25th, 2016, 10:38 am

Cardiac Rehab Plus Stress Management Boosts Outcomes

Coronary heart disease patients saw 50% fewer cardiac events
by Kay Jackson 03.21.2016
Contributing Writer, MedPage Today
This article is a collaboration between MedPage Today®

Action Points
Note that this randomized trial of cardiac rehabilitation versus cardiac rehabilitation plus stress management training demonstrated that the latter was associated with a reduced incidence of subsequent cardiac events.

Be aware the study was small and conducted in two centers. Results will require further validation.
The addition of stress management training (SMT) to cardiac rehabilitation in patients with coronary heart disease (CHD) markedly improved clinical outcome and reduced the number of subsequent cardiac events, the ENHANCED trial showed.

All patients undergoing cardiac rehabilitation (CR) showed improvements in blood lipid levels and other
cardiac biomarkers of risk following 12 weeks of rehab, according to James A. Blumenthal, PhD, of Duke University, and colleagues.

Patients who received cardiac rehab and SMT had 50% fewer cardiac events (18% vs 33%, HR 0.49, P=0.035) over a follow-up period of up to 5 years. In addition, greater reductions in stress were tied to a lower rate of clinical events (HR=0.58, 95% CI 0.34-0.99, P=0.048), they reported online in Circulation.
"The present findings indicate that SMT could be beneficial for all cardiac patients and suggest that SMT should be incorporated into comprehensive CR," the authors wrote. "A multi-site effectiveness trial will be needed to confirm the applicability of these findings to the larger CR population."

"The onus is on the physicians to recognize that stress management is important for the optimal medical management of patients," Blumenthal said in an accompanying statement.
"I think this is an important study reaffirming the benefits of cardiac rehab, and the importance of stress reduction as part of that rehab," noted Stuart D. Russell, MD, of Johns Hopkins Hospital, who was not affiliated with the study.

"We often underemphasize the importance of stress management to our patients and adding this component to cardiac rehab is clearly helpful," he told MedPage Today.

However, the trial did not show any mortality benefit for patients receiving cardiac rehab and cardiac rehab plus SMT, Russell pointed out.

"Every family physician in North America is going to be interested in these results," said Jaan Reitav, PhD, of the University Health Network in Toronto. Reitav, co-author of the Canadian Guidelines for Cardiac Rehabilitation (third edition), was not affiliated with the study.

"This study shows that cardiac rehab is important and stress management adds another layer of protection," Reitav told MedPage Today. "Blumenthal recommends including stress management as a standard component of cardiac rehab regardless of what the patient's stress level is. I totally agree with this."

He called the trial "a fair test using real people. They didn't 'cherry pick' their sample," he said. "They went to great lengths to choose the kinds of patients a family doctor would normally see, including those with heart failure and chronic kidney disease and so on."

In the ENHANCED (Enhancing Cardiac rehabilitation with stress management training in patients with heart disease) efficacy trial, 151 outpatients with CHD, ages 36 to 84, were randomized to 12 weeks of cardiac rehab (n=75) or cardiac rehab plus SMT (n=75) at either the Center for Living at Duke University, or UNC's Wellness Center.

Cardiac rehab consisted of 35 minutes of aerobic exercise three times a week, CHD education, nutritional counseling, and two classes on stress in CHD.

Patients who received identical cardiac rehab plus SMT also underwent 12 weekly 1.5-hour sessions of group support and cognitive behavior therapy. A matched sample of patients who didn't receive cardiac rehab made up a comparison group.

The study showed that patients who received cardiac rehab plus SMT had greater reductions in composite stress levels when compared with patients who received CR alone (P=o.o22). This was achieved through reductions in anxiety, distress, and perceived stress, the researchers said.
In addition, cardiac events such as heart attack, stroke, and recurrent angina requiring hospitalization were observed in 18% of patients who received cardiac rehab plus CMT compared with 33% of patients who received cardiac rehab alone (HR=0.49, P=0.035) and 47% of patients in the no-cardiac rehab comparison group (HR=0.44, P<.001).

Patients with greater stress often had more improvement, the investigators noted. "Depressive symptoms were reduced in both CR and CR+SMT groups, which is not surprising given that depressive symptoms are reduced by CR, and that exercise has been shown to reduce depressive symptoms in patients with major depression, stable CHD and heart failure," they wrote.

Finding ways to keep cardiac rehab patients active after their 12-week program is finished is "the most important thing we need to do," Russell said. "Unfortunately, we are not very good at keeping people going long-term."

He pointed out that the HF-ACTION trial of cardiac rehab in heart failure patients showed the group that benefited most stayed active following rehab. He also emphasized that patients need to change their lifestyles.

"It takes 30 seconds to pop a pill [but] patients need to ... take 30 minutes to exercise each day as well," he told MedPage Today.

The ENHANCED study findings run contrary to the 2012 RAMIT study report, which concluded comprehensive cardiac rehab had no effect on mortality, cardiac, or psychological morbidity, and that the value of cardiac rehab, as practiced in the U.K., was "open to question."

"Important differences in how CR is practiced in England and the U.S. may explain the discrepant results," the authors noted. For example, in RAMIT, weekly cardiac rehab was done for 6-10 weeks, whereas in the U.S.-based ENHANCED trial, patients engaged in exercise three times per week for 12 weeks, they explained.

Study limitations included the small sample size. The authors acknowledged that they "observed few 'hard' endpoints," such as death and nonfatal myocardial infarction. Also, those who volunteered for the study may have been highly motivated to participate in the program, which limits the generalizability of the findings.

Blumenthal and co-authors disclosed no relevant relationships with industry.
Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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Re: Coronary heart disease patients saw 50% fewer cardiac events

Post by Michael L » March 25th, 2016, 12:19 pm

Makes sense. I believe that stress, and our ability to deal with it plays an important role in our health.
Now, if I could just get my insurance company to authorize my attendance to a Cardiac Rehab Program!
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