350 Coronary Heart Disease and Hypertension
social and emotional support given to the patients that
helped ameliorate depression and feelings of distress, thereby
reducing physiological arousal and its negative effects on the
cardiovascular system. Speci“c aspects of the treatment pro-
gram, including its individualized interventions and treat-
ment based on an individual•s stress score, may have also
contributed to the programs success. However, these promis-
ing “ndings unfortunately do not hold up after additional
study. Frasure-Smith et al. (1997) conducted the Montreal
Heart Attack Readjustment Trial (M-HART), a randomized,
controlled study of 1,376 post-MI patients assigned to either
an intervention group, which received home-nursing visits
and monthly telephone monitoring to help deal with stress, or
a control group which received usual care. After one year, the
program was found to have no overall survival impact. In
fact, women in the intervention group had a higher cardiac
and all-cause mortality rate than women in the control group
(Figure 15.2). There was no evidence of either harm or bene-
“t for men and overall the programs impact on depression
and anxiety among survivors was small.
Despite the contradictory “ndings of these two studies, rel-
atively few clinical studies have been designed speci“cally to
reduce depressive symptoms or increase social support in pa-
tients with coronary disease. Based on strong epidemiological
evidence that depression and social support are linked to coro-
nary patients, the National Heart, Lung, and Blood Institute
(NHLBI) has recently launched the Enhancing Recovery in
CHD Patients (ENRICHD) study. The trial is studying 3,000
acute MI patients with depression or perceived low social
support at eight different sites over the sampling for women
and minorities. Patients were randomly assigned to a psy-
chosocial intervention group, with individual and group ther-
apy tailored to each patient•s needs, or a control group that
received only usual care. This is the “rst large, multicenter
clinical trial to study the effects of psychosocial interventions
on reinfarction and death in acute MI patients who are de-
pressed or have low social support. These “ndings could
pave the way for greater clinical acceptance of psychosocial
factors in the treatment and rehabilitation of cardiac patients
(The ENRICHD Investigators, 2000).Long-Term Lifestyle ChangesThe Lifestyle Heart Trial, which assessed whether coronary
patients could be motivated to and bene“t from making and
sustaining comprehensive lifestyle changes, is one of the
most important intervention studies conducted to date. Ornish
and colleagues (1990) randomized 48 patients with moderate
to severe coronary heart disease into two groups: an intensive
lifestyle change group (n28) and a control group (n20).
The intensive lifestyle change patients were given a lifestyle-
modi“cation program consisting of several components:1.A 10%-fat vegetarian diet.
2.Stress management training and group support including
yoga and mediation in group settings twice a week and in-
dividual practice for an hour each day.
3.Smoking cessation.
4.A program to moderate levels of aerobic exercise.Control group patients were not asked to make lifestyle
changes other than those recommended by their cardiolo-
gists. The intervention lasted one year and the extent of pro-
gression of coronary disease was assessed by comparing
coronary angiograms obtained at study onset and at one year.
Study results (Ornish et al., 1990) showed that after one
year, experimental group participants were able to make and
maintain lifestyle changes with bene“cial results, including a
37% reduction in low-density lipoprotein (LDL) cholesterol
levels, a 91% reduction in anginal episodes, and a slight re-
duction in the extent of stenosis (or blockage) in coronary ar-
teries. Controls had very different results, showing only a 6%
decrease in LDL cholesterol levels, a 165% increase in re-
ported anginal episodes, and a less signi“cant reduction in
the extent of stenosis in coronary arteries. Overall, 82% of
participants in the lifestyle intervention group had an average
change toward regression of disease. Interestingly, there was
a relationship between the extent of adherence to the lifestyle
change program and the measured degree of regression of
disease, with the most compliant study subjects showing the
most improvement in disease status (Figure 15.3).(^0100200300400)
90
95
100
Time from Discharge (Days)
% of Patients without
Cardiac Death
p 0.94
p 0.064
Intervention Men (n 458)
Control Men (n 445)
Intervention Women (n 234)
Control Women (n 239)
Figure 15.2 Cumulative survival during 365 days after discharge in Inter-
vention and control groups in the M-HART program. Reprinted with per-
mission from Frasure-Smith et al. (1997). Lancet, 350,473...479.