Coronary Heart Disease 349tolerance, helps in weight loss, lowers blood pressure, con-
trols glucose levels in diabetics, raises HDL cholesterol, and
lowers LDL cholesterol and triglycerides. Additionally, psy-
chological factors including anxiety and depression improve
for cardiac patients who undergo rehabilitation and physically
“t individuals also have attenuated hemodynamic and neu-
roendocrine responses to behavioral stressors (Blumenthal &
Wei, 1993; Lavie & Milani, 1997). Because recent evidence
suggests that stress management and pyschosocial treatments
have bene“cial effects on morbidity and quality of life, these
interventions are reviewed in detail in the following section.
Psychosocial Treatment Approaches/Implementation of
Lifestyle Changes
Modifying Hostility and Type ABehavior
A number of intervention studies have attempted to modify
Type A behavior in an attempt to reduce cardiovascular dis-
ease risk. Most early studies reported that elements of Type A
behavior can be decreased in subjects who are motivated to
change (Allan & Scheidt, 1996; Suinn, 1982). Nunes, Frank,
and Kornfeld (1987) performed a meta-analysis of relevant
literature and found that treatment of the Type A behavior
pattern using a combination of treatment techniques reduced
coronary events by about 50%. This “nding should be taken
cautiously, however, for it was based on a limited number of
studies conducted prior to 1987.
The Recurrent Coronary Prevention Project (RCPP)
(Friedman et al., 1986) was the “rst and most ambitious in-
tervention trial to solely study whether Type A behavior
could be modi“ed, and how this modi“cation might impact
one•s risk of cardiovascular morbidity and mortality. The
study looked at a variety of Type A behaviors, including
anger, impatience, aggressiveness, and irritability. Over
1,000 patients were assigned to one of three groups: a cardi-
ology counseling treatment group, a combined cardiology
counseling and Type A behavior modi“cation group, or a
nontreatment control group. The cardiology counseling in-
cluded training on how to comply with drug, dietary, and ex-
ercise regimens as dictated by the participant•s physician,
counseling on non-Type A psychological problems resulting
from the coronary experience, and education about all as-
pects of cardiovascular disease. Type A counseling included
drills to modify various Type A behaviors, discussions on val-
ues and beliefs that may cause the behavior pattern, relax-
ation and stress reduction training to decrease physiological
arousal, and changes in work and home demands.
After 4.5 years, the “nal results showed a lar ger decrease
in global Type A behaviors as well as in its components in the
Type-A counseling group. Also, rate of recurrent MI was sig-
ni“cantly lower in the Type-A counseling group than in either
the cardiology counseling or control groups (Friedman et al.,
1986). However, recent evidence points to the fact that much
of the reduced cardiac recurrences in the Type A counseling
group may be attributed to multiple causes, including in-
creased number of treatment contacts and increased social
support (Mendes de Leon, Powell, & Kaplan, 1991).
Hostility is a speci“c component of Type A behavior that
is a signi“cant psychosocial risk factor for cardiovascular
disease development. Girdon, Davidson, and Bata (1999)
studied the effects of a hostility-reduction intervention on pa-
tients with coronary heart disease. Twenty-two highly hostile
male coronary patients were randomly assigned to either a
hostility intervention group or an information-control group.
Those in the intervention group were observed at immediate
and two-month follow-ups to be less hostile than controls, as
assessed using self-report and structured interviews, and to
have signi“cantly lower diastolic blood pressures. Further in-
vestigations promise to provide insight into the role of hostil-
ity reduction in relation to cardiovascular disease.Interventions to Increase Social Support and
Reduce Life StressThe Ischemic Heart Disease Life Stress Monitoring Program
(Frasure-Smith & Prince, 1987, 1989) was based on prior
studies that indicated that periods of increased life stress may
precede recurrences of MI (e.g., Rahe & Lind, 1971; Wolff,
1952). Post-MI patients were either assigned to a treatment
group (n= 229), which included life stress monitoring and in-
tervention, or a control group (n= 224), which received only
routine medical follow-up care. Patients in the treatment
group were contacted by phone on a monthly basis and asked
to rate 20 symptoms of distress, including insomnia and feel-
ings of depression. If stress levels surpassed a critical level
(more than 4 of the 20 symptoms), a project nurse made a
home visit to attempt to help the patient assess the cause of
the distress and to help the patient cope with the stressors.
Over a one-year period, nearly half of the treatment group
needed an intervention and received on average “ve to six
hours of counseling, education on heart disease, and emo-
tional and social support. Results showed that during the year
of the project there was a 50% reduction in cardiac deaths, a
reduction that continued for six months beyond the project•s
completion. Over seven years following the study, there were
fewer MI recurrences among patients in the treatment group
(Frasure-Smith & Prince, 1989).
The success of the Ischemic Heart Disease Life Stress
Monitoring Program could at least partly be attributed to the