348 Coronary Heart Disease and Hypertension
Stress Reactivity
It was proposed that acute and chronic stress may lead to car-
diac pathology via neural, endocrine, and cardiovascular path-
ways (Krantz, Kop, Gabbay, et al., 1996). Research has long
shown that individuals physiologically respond differently to
stress and that these responses (termed reactivity) to emotional
stress may play a role in the development of cardiovascular dis-
eases and/or high blood pressure (see Krantz & Manuck, 1984;
Manuck, 1994). Reactivity is measured by assessing the car-
diovascular and/or hormonal changes in response to stress as
compared to resting levels of physiological variables. Individ-
uals vary greatly in the magnitude of physiological responses
to stress, with some people (•hot reactorsŽ)demonstrating siz-
able increases in response to challenging tasks, while others
show little or no changes from resting levels. For example,
some evidence indicates that behaviors associated with hostile
Type A individuals are accompanied by similar kinds of car-
diovascular and neuroendocrine responses thought to link psy-
chosocial stress to cardiovascular disease (Contrada & Krantz,
1988; Krantz & Durel, 1983; Matthews, 1982). Researchers
have explored the possibility that excessive reactivity to stress
may itself be a risk factor or marker of risk for coronary dis-
ease. One study followed initially healthy men for 23 years and
found the magnitude of their diastolic blood pressure reactions
to a cold pressor test (immersing the hand in cold water) pre-
dicted later heart disease to a greater degree than standard risk
factors assessed in the study (Keys et al., 1971). However, a
later study (Coresh, Klag, Mead, Liang, & Whelton, 1992)
failed to replicate these results. More recently, we observed
that, among cardiac patients, high diastolic blood responders to
stress were more likely to suffer cardiac events over a 3.5 year
follow-up period (Krantz et al., 1999).
Treatment of Coronary Heart Disease
Medical and surgical treatment for coronary heart disease has
made great strides in the past 30 years. Among the major de-
velopments include a variety of effective cardiac medications
and procedures (e.g., coronary angioplasty). Nevertheless,
evidence suggests that behavioral interventions can further
improve medical and psychological outcomes in CAD. In
this section, we review medical and surgical management ap-
proaches, followed by a discussion of behavioral and lifestyle
treatments.
Medical and Surgical Treatment
Current guidelines for medical treatment of CHD include
aspirin, which reduces clotting of platelets in the arteries,
beta-blockers and calcium channel blockers, which act to re-
duce ischemia and may help to prevent myocardial infarction
and sudden death, long acting nitrates, to dilate arteries in
order to reduce angina, and lipid lowering drugs, which lower
dangerous cholesterol levels. A now common medical proce-
dure aimed to open up blocked coronary arteries, percuta-
neous transluminal coronary angiography (PTCA), involves
threading a catheter-borne balloon up to the heart via the
groin. The balloon is in”ated at the site of blockage. By the
same method, stents (coiled wires that provide structural sup-
port to an artery) are placed at the blockages or rotating
blades break up plaque. The surgical treatment for CHD is
coronary artery bypass graphing (CABG), during which the
heart is revascularized by bypassing diseased arteries with
veins from the leg or with an artery from the chest. Studies
like the Veteran•s Administration Cooperative Study (VA
Study), the Coronary Artery Surgery Study (CASS), and the
European Coronary Surgery Study (ECSS) compared the ef-
“cacy of these treatments and found that for patients that
have three or more vessels or the important left main vessel
diseased have a greater 10-year survival if surgically treated
with CABG. Those patients without left main coronary in-
volvement and less than three vessels diseased show no dif-
ference in prognosis between medical and surgical therapy,
although surgery provides more symptom relief and better
quality of life (Gibbons et al., 1999).Exercise and Behavioral Components of
Cardiac RehabilitationCardiac rehabilitation, or risk factor intervention, aims to ex-
tend survival, improve quality of life, decrease the need for
interventional procedures, and reduce incidence of myocar-
dial infarction. Combined with medical and surgical treat-
ment, comprehensive cardiac rehabilitation is shown to
improve outcomes for coronary heart disease patients includ-
ing the elderly and women (Eagle et al., 1999). The American
Heart Association•s recommendations for comprehensive
risk reduction involve complete cessation of smoking, lipid
management through drug treatment, and a diet low in satu-
rated fats, physical activity a minimum of 30 minutes three
times a week, weight management, blood pressure control
through diet, reduced alcohol intake, sodium restriction, and
estrogen replacement therapy for postmenopausal women
(Smith et al., 1995). Evidence supports that these more mod-
erate lifestyle changes correlate with less disease progression
(Gibbons et al., 1999).
Exercise training is often the core of a cardiac rehabilita-
tion program, since physical inactivity is an independent
risk factor for CHD. Aerobic exercise increases exercise