Adding stress management to cardiac rehabilitation improves recovery in people with heart disease, researchers reported Monday.

Cardiac rehabilitation programs do not routinely offer stress management, but that could change should demand increase, said the study’s lead researcher James A. Blumenthal, Ph.D., professor of Psychiatry and Behavioral Sciences at Duke University School of Medicine in Durham, North Carolina.

“And because patients may be reluctant to ask for the programs themselves, the onus is on the physicians to recognize that stress management is important for the optimal medical management of patients,” Blumenthal said.

The new research appears in the American Heart Association’s journal Circulation.

After a median follow-up of more than three years, researchers found that patients who received cardiac rehab plus stress management achieved greater benefits than those receiving rehab alone. Heart attack, stroke, recurrent chest pains requiring hospitalization, or death were observed in:

  • 18 percent of patients in the rehab plus stress management group;
  • 33 percent of patients in the cardiac rehab-only group; and
  • 47 percent of patients who had no rehab.

The researchers noted that stress reduction was linked to a 50 percent lower risk of cardiac events in the rehab plus stress management group, compared to the rehab-alone group.

The study, called ENHANCing Cardiac rEhabilitation with stress management training in patients with heart Disease, or ENHANCED, included 151 patients ages 36 to 84 from two centers in North Carolina. One group received 12 weeks of comprehensive, exercise-based cardiac rehabilitation. The other group received the same cardiac rehabilitation plus a weekly 1.5-hour group stress management program for 12 weeks. Stress management included small-group discussions, relaxation training and training in coping skills and stress reduction.

A third group of 75 patients, matched for age and medical conditions who chose not to participate in cardiac rehabilitation, served as a comparison group.

Overall, patients in both rehab groups saw improved levels of blood lipids, lower heart rates during exercise, better exercise tolerance and improvements in other areas after 12 weeks of rehab.

Only 20 percent to 30 percent of patients eligible for cardiac rehabilitation participate, Blumenthal estimated, possibly because of accessibility, cost or low rates of referrals. Some also may try to rehabilitate on their own. “Despite their good intentions, making lifestyle changes is not an easy thing to do without assistance,” he said.

The results of ENHANCED contradict those of a recent British study that found cardiac rehabilitation did not add value to the medical management of heart patients and that the stress management program was not effective. In the British study, however, cardiac rehab was performed weekly or biweekly for 6 to 8 weeks. In ENHANCED, rehab participants engaged in aerobic exercise three times a week for 12 weeks, took nutrition classes and were counseled on smoking cessation.