LETTERS TO THE EDITOR
Cardiac Rehabilitation, Exercise Training, and Psychosocial Risk Factors: REPLY
Alan Rozanski, MD* and
James Blumenthal, PhD
* St. Luke's/Roosevelt Hospital, Department of Medicine, 1111 Amsterdam Avenue, New York, New York 10025-1716 (Email: ar77{at}columbia.edu).
We agree with Drs. Lavie and Milani that exercise is a well-established intervention for the secondary
prevention of coronary heart disease (CHD), and is a major component of cardiac rehabilitation
programs (1,2). We also are aware that cardiac rehabilitation services are seriously underutilized.
For example, according to a recent position paper from the American Heart Association (3) only
10% to 20% of eligible patients actually participate in cardiac rehabilitation. A meta-analysis (4)
reported results from 32 studies with 16,804 patients eligible for cardiac rehabilitation and
reported that only 25% to 31% of eligible men and 11% to 20% of eligible women participated. It is
evident that many physicians do not refer patients to cardiac rehabilitation, and this reluctance is
especially true for women and minorities (5).
As alluded to by Drs. Lavie and Milani, exercise cannot only induce beneficial physiological
adaptations, but can also improve psychological functioning. For example, in a recent randomized
trial, exercise training decreased depressive symptoms as effectively as antidepressant
medication in patients with clinical depression (6,7). Other work by Thayer et al. (8) has
demonstrated that even short bursts of exercise activity can effectively increase energy or
decrease tension for two-hour periods. Recent data also emphasize the beneficial effects of
exercise on cognitive function and brain plasticity (9). However, because poor adherence to
exercise training is relatively common, effective strategies for optimizing patient adherence are
needed (10).
It also should be noted that, though there is an extensive literature documenting the value of
exercise in patients with coronary artery disease (CAD), data regarding the significance of stress-management training in
improving clinical outcomes are limited. A nonrandomized trial of patients with stable CHD
showed that stress-management training was associated with reduced ischemia, fewer cardiac
events, and lower medical costs compared to usual care controls (11,12). In the absence of data
from large multicenter randomized clinical trials with "hard" clinical end points, we advocate for
smaller studies using intermediate biomarkers of cardiovascular risk (13). For example, in a
recent study (14) both exercise and stress-management training were found to reduce myocardial
ischemia and improve vascular endothelial function, compared to usual care. Furthermore, stress
management was actually superior to exercise training in improving measures of heart rate
variability and baroreflex sensitivity. These data would strongly support the potential clinical
benefits of both exercise and stress management in the routine care of patients with CHD.
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References
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1 Ades PA. Cardiac rehabilitation and secondary prevention of coronary heart disease N Engl J Med 2001;345:892-902.[CrossRef][Web of Science][Medline]2 Wenger NK, Froehlicher ES, Smith LK, et al. Cardiac rehabilitation: clinical practice guidelines. Rockville, MD: Agency for Health Care Policy and Research and the National Heart, Lung and Blood Institute, 1995; ACHPR publication no. 96-0672.. 3 Leon AS, Franklin BA, Costa F, et al. Cardiac rehabilitation and secondary prevention of coronary heart disease Circulation 2005;111:369-376.[Abstract/Free Full Text] 4 Jackson L, Leclerc J, Erskine Y, Linden W. Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors Heart 2005;91:10-14.[Abstract/Free Full Text] 5 Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial infarction in the community J Am Coll Cardiol 2004;44:983-996. 6 Blumenthal JA, Babyak MA, Moore KA, et al. Effects of exercise training on older patients with major depression Arch Intern Med 1999;159:2349-2356.[Abstract/Free Full Text] 7 Babyak MA, Blumenthal JA, Herman S, et al. Exercise treatment for major depression: maintenance of therapeutic benefit at 10 months Psychosom Med 2000;62:633-638.[Abstract/Free Full Text] 8 Thayer RE, Newman JR, McClain TM. Energy, tiredness, and tension effects of a sugar snack vs moderate exercise J Pers Soc Psychol 1987;52:119-125.[CrossRef][Web of Science][Medline] 9 McAuley E, Kramer AF, Colcombe SJ. Cardiovascular fitness and neurocognitive function in older adults: a brief overview Brain Behav Immun 2004;18:214-220.[CrossRef][Web of Science][Medline] 10 Rozanski A. Integrating psychologic approaches into the behavioral management of cardiac patients Psychosom Med 2005;67(Suppl 1):S67-S73.[Abstract/Free Full Text] 11 Blumenthal JA, Jiang W, Babyak MA, et al. Stress management and exercise training in cardiac patients with myocardial ischemiaEffects on prognosis and evaluation of mechanisms. Arch Intern Med 1997;157:2213-2223.[Abstract/Free Full Text] 12 Blumenthal JA, Babyak M, Wei J, et al. Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men Am J Cardiol 2002;89:164-168.[CrossRef][Web of Science][Medline] 13 Rozanski A, Blumenthal JA, Davidson KW, et al. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology J Am Coll Cardiol 2005;45:637-651.[Abstract/Free Full Text] 14 Blumenthal JA, Sherwood A, Babyak M, et al. Effects of exercise and stress management training on markers of cardiovascular risk in patients with ischemic heart disease: a randomized controlled trial JAMA 2005;293:1626-1634.[Abstract/Free Full Text]
Related Article
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Cardiac Rehabilitation, Exercise Training, and Psychosocial Risk Factors
- Carl J. Lavie and Richard V. Milani
J. Am. Coll. Cardiol. 2006 47: 212.
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