A Controlled Pilot Study of Stress Management Training of Elderly Patients With Congestive Heart Failure
from Preventive Cardiology
Reprinted from Medscape.com
Frederic Luskin, PhD, Megan Reitz, BA, Kathryn Newell, MA, Thomas Gregory Quinn, MD, William Haskell, PhD
Abstract and Introduction
The purpose of this study was to evaluate the effect of stress management training on quality of life, functional capacity, and heart rate variability in elderly patients with New York Heart Association class I-III congestive heart failure (CHF). While substantial research exists on stress management training for patients with coronary heart disease, there are few data on the value of psychosocial training on patients with CHF. Thirty-three multiethnic patients (mean age, 66±9 years) were assigned through incomplete randomization to one of two treatment groups or a wait-listed control group. The 14 participants who completed the treatment attended eight training sessions during a 10-week period. The training consisted of 75-minute sessions adapted from the Freeze-Frame stress management program developed by the Institute of HeartMath. Subjects were assessed at baseline and again at the completion of the training. Depression, stress management, optimism, anxiety, emotional distress, and functional capacity were evaluated, as well as heart rate variability. Significant improvements (p<0.05) were noted in perceived stress, emotional distress, 6-minute walk, and depression, and positive trends were noted in each of the other psychosocial measures. The 24-hour heart rate variability showed no significant changes in autonomic tone. The authors noted that CHF patients were willing study participants and their emotional coping and functional capacity were enhanced. This program offers a simple and cost-effective way to augment medical management of CHF. Given the incompleteness of CHF medical management and the exploding interest in complementary medical intervention, it seems imperative that further work in psychosocial treatment be undertaken.
Congestive heart failure (CHF) is the only major cardiovascular disorder that is increasing in incidence, prevalence, and overall mortality. Recent studies estimate the prevalence of CHF at almost 5 million persons in the United States, leading to hospitalization of 900,000 patients each year.  Improvements in survival after myocardial infarction, better management of diabetes and hypertension, and an increase in the aging population have contributed to the rise in CHF.  The hallmark of CHF is exercise intolerance and activity restriction, most commonly due to symptoms of dyspnea and fatigue. These symptoms are debilitating and result in low functional capacity and progressive physical disability, often requiring intensive medical management, follow-up, and hospitalization.
In addition to physical decline, these patients often report depressed mood, anxiety, and increased hostility.  A structured interview with 60 hospitalized CHF patients (aged 70+ years) showed that 17% of the participants met the Revised Diagnostic and Statistical Manual of Mental Disorders (DSM III) criteria for major depression. The patients who were depressed required a greater number of inpatient hospital days and, at 1 year, showed greater mortality. 
Patients with CHF are known for very high mortality rates, as well as the highest hospital readmission rates of all patient populations.  This may be partly due to the psychosocial consequences of the disease process, which includes behavioral restrictions, as well as comorbid depression and anxiety. A study that evaluated quality of life of CHF patients found no significant relationship between a patient's cardiac ejection fraction and any quality of life measure.  However, self-reported functional status, depression, and hostility were significant indicators of quality of life among these patients.
Recent studies have shown that sympathetic activation is one of the hallmark physiologic abnormalities in CHF. Circulating catecholamine levels have been associated with increased severity of disease and unfavorable prognosis.  As a result of these studies, the "neurohormonal" hypothesis has emerged as the leading paradigm for understanding the progression of CHF. 
Pharmacologic therapies that alter autonomic balance, such as angiotensin-converting enzyme inhibitors and blocking agents, have become standard therapy for CHF patients.  However, noncompliance can be a significant problem in pharmacologic treatment. Monane et al.  noted that among elderly CHF patients on digoxin, only 10% were completely compliant with the prescribed regimen over the course of a year. The use of blockers elicits better adherence, yet medical management of CHF is still incomplete.  Sullivan and Hawthorne  reviewed the nonpharmacologic interventions for CHF. They cite the effectiveness of long-term aerobic exercise conditioning programs and make the case for offering psychological and biobehavioral interventions to enhance outcome and quality of life.
To test their hypothesis, they examined the effect of structured nursing care for CHF patients in order to reduce readmission rates and improve quality of life.  The study results showed that patients with CHF experienced major mood disturbances greater than those reported by other cardiac patients. This mood disruption was directly related to patients' quality of life and highlighted the need for concurrent psychosocial intervention. Interestingly, this study found exercise tolerance to be unrelated to patients' ejection fractions but related to quality of life.
To date, there are two studies that included a psychosocial intervention as an aspect of a clinical trial. As one arm of a study, CHF patients were offered an intervention that included exercise training, structured cognitive therapy, and dietary training. This intervention improved functional capacity, body weight, and mood state.  The second  was a pilot study in which New York Heart Association (NYHA) class II-IV CHF patients taught the Freeze-Frame  stress management program showed significant improvement in coping with stress and a trend toward increased self-confidence related to their physical fitness. Previous research had shown the short-term positive effects of Freeze-Frame to include enhancement of heart rate variability and modification of sympathetic arousal in healthy volunteers. [15,16] This study attempted to measure participants' autonomic balance, but the severity of NYHA class III-IV CHF prevented adequate recording of 24-hour heart rate variability. Compromised heart rate variability was the factor that best predicted early death from progressive heart failure. 
Stress management and relaxation training are psychosocial practices that can reduce sympathetic arousal. Research shows the usefulness, in both primary and secondary prevention, of stress management training in patients with coronary artery disease.  This current study builds upon the authors' previous study through recruiting and randomization of a larger number of participants with less severe CHF.
Research Design and Methods
The initial study sample consisted of 13 men and 20 women with an average age of 66±9 years. Thirteen participants were middle-class Anglo-Americans, with one Asian American woman, and were invited to participate by the nurse at a local cardiac rehabilitation facility. Nineteen participants were inner city, low socioeconomic status African American, Asian American, or Latino patients, and were invited to participate by their cardiologists.
Subjects had been diagnosed as having NYHA class I to very early class III CHF at least 3 months previously and had been on a stable medication regimen for at least 1 month. A cardiologist evaluated each patient's medical file and certified each participant as eligible for the study. Stanford University's Institutional Review Board approved this project.
Participants were assigned to either of two treatment groups or to the wait-listed control group through incomplete randomization. Full randomization was attempted, but because only one class was held per location, four participants in the treatment group could not make the training sessions and became control group participants. Subsequently, five control group members were assigned to the treatment groups. Control group members were invited to attend a 1-day training at the completion of the intervention.
All participants received the same 10 hours of training offered during eight weekly 75-minute sessions spread over 10 weeks. The two treatment groups followed the same topical outline that was taught by one of the authors (Frederic Luskin), a licensed psychotherapist. The training was primarily didactic in nature, with an emphasis on guided practice of the techniques. A limited amount of time was set aside for participant sharing of personal experience. After each session, participants were given practice assignments for the week.
The stress management techniques taught were Freeze-Frame, Heart Lock-in, Appreciation and Care vs. Overcare. Freeze-Frame is the basic stress management technique and starts with the conscious shifting of attention from a stressful experience to the area around one's heart. After taking a few slow, deep breaths into the area around the heart, one's attention is drawn to a visualization or memory of a positive emotion, such as care or love. Then the feeling generated by that positive emotion is held in the area around the heart. Heart Lock-in is an extended Freeze-Frame, while Appreciation is learning to focus attention on positive experiences. Care is distinguished from Overcare. Overcare is defined as the tendency to want something or someone so much that the extra effort and/or anxiety obscures the positive experience of care and leads to distress.
Dave Murphy, Ph.D.
is a clinical
psychologist specializing in behavioral medicine, with an emphasis on cardiac care.
In association with:
Santa Rosa Memorial Hospital