Stop Stressing

Stress management during cardiac rehabilitation is key to long-term recovery

Cardiac rehabilitation is an essential part of recovery from a heart attack, cardiac surgery or other adverse event.  Traditional cardiac rehab includes physical activity, adapting a heart-friendly diet and taking medications to manage high blood pressure and high cholesterol.

But what if there were another aspect to the recovery process that was equally important? What about the mental and psychosocial aspects of recovery? A clinical trial of 151 coronary heart disease patients conducted by Duke Health and UNC Health Care studied patients who received traditional regimens of cardiac rehabilitation for 3 months. In addition, half of the patients attended weekly 90-minute stress management group classes. Those meetings consisted of cognitive behavioral therapy, muscle relaxation exercises, group support and other techniques to lower stress.

Positive Additions
Three years later, 33% of the patients who received just cardiac rehabilitation had suffered from a second adverse event, like hospitalization due to chest pain, heart attack, stroke, bypass surgery, or death from any cause.  Eighteen percent of the cohort who additionally received stress management support had suffered cardiac events.

To validate the overall importance of cardiac rehabilitation, researchers also looked at similar sized sample group of eligible patients who chose not to receive any form of rehabilitation. Forty-seven percent of that group suffered a second incident or died from any cause.1

“It reinforces the value of cardiac rehab for patients who suffered an acute cardiac event,” noted James Blumenthal, PhD, clinical psychologist and professor in psychiatry and behavioral science at Duke University and one of the study’s co-authors.

Nurses as Heart Champions
Kathy Berra, MSN, ANP, FAHA, FPCNA, FAAN, clinical director, Stanford Heart Network, Stanford Prevention Research Center, a respected cardiac nurse who was not involved with this study, said, “Nurses bring experience in pathophysiology and medical management and surgical management of heart disease.”  They understand the importance of physical activity as part of recovery and can teach patients how to monitor their heart rate and when to slow down and when to work harder during exercise.

Nurses also understand the role poor diet plays in contributing to adverse cardiac events, and can use their platforms to advise patients on healthy eating. Data has shown that people who are under a lot of stress tend to eat more high fat foods and consume more alcohol, two contributing factors to heart disease.

Cardiac rehab nurses like Berra are well versed in other risk factors, like smoking, obesity, and of course, stress.

Stop Stressing
The researchers hypothesized the stress management component would be beneficial. High stress levels have been associated in worse outcomes in heart disease patients. The American Heart Association names stress as a risk factor for cardiac patients. Depression post heart attack, which can be closely related to stress, can raise the risk of death for those patients two to four times, according to Blumenthal.

Berra explained, “The mind and the body are very well-connected.  There’s no question that stress adds to risk factor profile but it’s little hard to measure. ” Berra cited the work of Dean Ornish, MD, which evaluated the effect of stress on the heart years ago.

Blumenthal admitted, “There is not a single gold standard for measuring stress which is part of the problem. In the Duke/UNC study, researchers took central elements of stress-depression, anxiety, anger and people’s self-perceptions of their stress levels. They combined existing scales into one composite measurement of stress levels to evaluate the participants.

He acknowledged, “The stress factor was more nebulous and patients were reluctant to admit they were stressed.”  Clinicians should get patients to recognize stress is important to their recovery.  Simply recognizing how stressful having heart disease can be is an important step.

Providing Encouragement
“Nurses can listen and advise,” remarked Berra. “Nurses are educators and that important for cardiac rehab.” They remind patients of the entire package of what needs to be addressed.

Nurses assess how patients feel.  Some clinicians may merely pay lip service to stress reduction, giving a lecture but not offering actionable coping skills.  Encouraging patients to join stress management classes, teaching relaxation exercises, suggesting helpful books and referring patients to other providers who could help them further, are all useful actions nurses can take on behalf of cardiac patients.

“Patients also provided with stress management received greater psychological benefit,” noted Blumenthal. The participants in the Duke/UNC study had varying self-reported levels of stress. “Even if you’re not stressed, you can still benefit. For a relatively small investment, there is a lot to be achieved.”

Adding stress management to already important cardiac rehab provides added value.  “Nurses have a wealth of knowledge about the treatment of heart disease,” explained Berra. Together with other clinicians, they can foster healthy behaviors in their cardiac patients, lowering the chance for a repeat offense.


  1. UNC Healthcare. Adding stress management to cardiac rehab cuts new heart incidents in half.  March 21, 2016. Available at

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