12

RESEARCH FINDINGS USING GUIDED IMAGERY FOR
Coronary Heart Disease

July, 2006


Definition of the Problem
Coronary heart disease (CHD) results when deposits called plaques build up in arteries. This leads to atherosclerosis, a condition that reduces blood flow and oxygen. CHD, also called coronary artery disease (CAD), develops over time, and leads to partial or complete blockage of the arteries involved. One major cause of atherosclerosis is having high lipids (fats) such as cholesterol and triglycerides in the blood. Other major causes are hypertension, and smoking. Stress, obesity, and a sedentary lifestyle also contribute to the development of CHD. Other risk factors are heredity, race, age, diabetes, depression, low socioeconomic status, social isolation, and male gender.

CHD can be “silent,” producing no symptoms, or patients can experience shortness of breath, dizziness, chest pain (angina), or a heart attack.


Scope and Cost of the Problem
According to the National Heart, Lung, and Blood Institute, American Heart Association, as of 1999approximately 13 12.6 million Americans haved CHD. The direct and indirect costs of CHD to the U.S. economy exceed $351.8129.9 billion annually (AHA, 2002).2 Medicare alone spends more than $10.6 billion annually in its treatment (AHA, 2001).3 The most common form of heart disease, CHD is the leading cause of permanent disability in the U.S, and is the primary cause of death in Americans, both male and female -- over 500725,000 deaths annually (NHLBI).4


Medical Treatment
Treatment for CHD depends on many factors, including the severity of the disease and any comorbid conditions. Frequent treatments include aspirin, beta-blockers, nitrates, lipid-lowering medications, and ACE inhibitors. Surgical procedures include coronary artery bypass, and angioplasty. Recommended lifestyle changes include quitting smoking, maintaining correct weight, regular exercise, and following a diet low in fat and cholesterol (Bass, 2001).5


Lifestyle Changes, Emotions, and Well-Being
A landmark 1998 study by Dean Ornish and associates demonstrated that lifestyle changes (diet, exercise, relaxation, and social support) can dramatically reverse CHD (Ornish, Scherwitz, et al, 1998).6 Other studies have shown that emotions play a major role in CHD. Fear, grief, and anxiety can trigger cardiac events (Ornish, 1998; Verrier and Mittleman, 1997; Williams, Kiecolt-Glaser, et al, 1999).7-9 Anger can be a trigger (Boltwood, Taylor, et al, 1993; Ironson, Taylor, et al, 1993; Verrier, Hagestad and Lown, 1987; Verrier, Mittelman, et al, 1995)7,10-13, and depression can affect the outcome of long-term survival (Barefoot, Brummett, et al, 2000).14 The role of stress in the development and progression of CHD both in men and women is also well documented (Allison, Williams, et al, 1995; Bairey, Krantz and Rozanski, 1990; Nordstrom, Kwyer, et al, 2001; Orth-Gomer, Wamala, et al, 2000; Sheps, McMahn, et al, 2002).15-19


Mind-Body Approaches Including Guided Imagery
Relaxation, and guided imagery, and other mind-body intervensions can reduce the impact of CHD both psychologically and physiologicallyin several ways.

Anger and other possibly harmful emotional states are reduced by the inner-focused, relaxed state induced by guided imagery and other mind-body modalities. Additionally, a sense of emotional well-being can be improved by the use of these therapies. Guided imagery and relaxation can reduce stress, and lower heart rate and blood pressure Hermann, 2002; .20-23 (Crowther, 1983; Hermann, 2002; Pender, 1985; Sharpley, 1994; Taylor, Farquhar, et al, 1977). Meditation produces similar physiological results Barnes, Treiber, et al, 2004; Castillo-Richmond, Schneider, et al, 2000; Zamarra, Schneider, et al, 1996; Lin, Nahin, et al, 2001), as does biofeedback, with or without imagery (Nakao, Yano, et al, 2003).24-25 Yoga that combined both postures and yogic breathing produced significant positive levels of blood lipids in those patients who participated in the program (Bijlani,Vempati, et al, 2005). Raja yoga improved respiratory functions, cardiovascular parameters and lipid profile (Vyas & Dikshit, 2002).

According to a review of 23 major heart disease studies, when psychosocial approaches were added to standard medical treatments, survival and further cardiac event rates improved significantly (Linden, Stossel and Maurice, 1996).26 A more recent review also confirmed that relaxation training can help patient recover from a cardiac events, reduce future angina and arrhythmias, and speed the time it takes to return to work (van Dixhoorn and White, 2005). Complementary approaches like relaxation training and imagery are so effective that they are routinely done at prestigious facilities such as Columbia Presbyterian Hospital’s Department of Surgery (Oz, Lemole et al, 1996).27 Relaxation, imagery, and education are important parts of Stanford’s Chronic Disease Self-Management Program (Lorig, Sobel et al, 1999). Use of guided imagery in cardiac patients 28 has led to shorter hospital stays, lower pharmacy costs, and lower use of pain medication (Halpin, Speir, et al, 2002).


The results of a lifestyle study showed that 80% of people who used complementary approaches were able to avoid cardiac surgery – a savings of almost $30,000 per patient (Ornish, 1998).29 Quality of life can also improve (Chang, Hendricks, 2005). Self-management of chronic conditions including CHD improves symptom management and reduces medical costs (Lorig, Sobel et al, 1999).28 In assessing the its importance, researchers van Dixhoorn and White deemed relaxation training “an important ingredient of cardiac rehabilitation” (2005).


Conclusion
A low-cost guided imagery-based program can help to lower stress and blood pressure, enhance an overall sense of emotional well-being, and improve compliance with lifestyle changes. Each of these factors, in turn, can aid in slowing, halting or reversing the progression of CHD and in reducing the number of further coronary events, re-hospitalizations, and surgeries.


References
1. American Heart Association. (2002). 2003 Heart and Stroke Statistical Update. Dallas, Texas. Pg. 4.
www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf Accessed: September, 2003.

2. American Heart Association. (2002). 2003 Heart and Stroke Statistical Update. Dallas, Texas. Pg. 11.
www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf Accessed: September, 2003.

3. American Heart Association. (2001). 2002 Heart and Stroke Statistical Update. Dallas, Texas: American Heart Association. www.americanheart.org/downloadable/heart/10148328094661013190990123HS_State_02.pdf. Pg. 12.
Accessed: September, 2003.

4. www.nhlbi.nih.gov/health/public/heart/other/chdfacts.htm)

5. Baas, A. MD (2001). Chronic Ischemic Heart Disease in Best Practice of Medicine. Accessed at Merck Praxis MD http://merck.praxis.md/bpm/bpm.asp?page=BPM01CA05

6. Ornish, D., Scherwitz, L.W., Billings, J.H., Brown, S.E., Gould, K.L., Merritt, T.A., Sparler, S., Armstrong, W.T., Ports, T.A., Kirkeeide, R.L., Hogeboom, C, Brand, R.J. (1998). Intensive lifestyle changes for reversal of coronary heart disease. JAMA, Dec 16;280(23):2001-7.

7. Verrier, R.L., Mittelman, M.A. (1997). Cardiovascular consequences of anger and other stress states. Baillieres Clin Neurol, Jul;6(2):245-59.

8. Williams, R., Kiecolt-Glaser, J., Legato, M.J., Ornish, D., Powell, L.H., Syme, S.L., Williams, V. (1999). The impact of emotions on cardiovascular health. The Journal of Gender-Specific Medicine, 2[5]:52-58.

9. Ornish, D. (1998). Love & Survival: The Scientific Basis for the Healing Power of Intimacy. New York, NY: HarperCollins.

10. Mittleman, M.A., Maclure, M., Sherwood, J.B., et al.(1995). Triggering of acute myocardial infarction onset by episodes of anger. Circulation, 92:1720-1725.

11. Ironson, G., Taylor, C.B., Boltwood, M., et al. (1993). Effects of anger on left ventricular ejection fraction in coronary artery disease. Am J Cardiol, 70:281-285.

12. Boltwood, M.D., Taylor, C.B., Boutte Burke, M., et al. (1993). Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments. Am J Cardiol, 72:1361-1365.

13. Verrier, R.L., Hagestad, E.L., Lown, B. (1987). Delayed myocardial ischemia induced by anger. Circulation, 5:249-254.

14. Barefoot, J.C, Brummett, B.H., Helms, M.J., Mark, D.B., Siegler, I.C., Williams, R.B. (2000). Depressive Symptoms and Survival of Patients with Coronary Artery Disease. Journal of Psychosomatic Medicine, Nov-Dec; 62(6): pp790-5.

15. Orth-Gomer, K., Wamala, S.P., Horsten, M., Schenck-Gustafsson, K., Schneiderman, N., Mittleman, M.A. (2000). Marital Stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. JAMA, Dec 20; 284 (23): pp. 3008-3014.

16. Sheps, D.S, McMahon, R.P., Becker, L., Carney, R.M., Freedland, K.E., Cohen, J.D., Sheffield, D., Goldberg, A.D., Ketterer, M.W., Pepine, C.J., Raczynski, J.M., Light, K., Krantz, D.S., Stone, P.H., Knatterud, G.L., Kaufmann, P.G. (2002). Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study. Circulation, Apr 16;105:1780–1784.

17. Bairey, C.N., Krantz, D.S., Rozanski, A. (1990). Mental stress as an acute trigger of ischemic left ventricular dysfunction and blood pressure elevation in coronary artery disease. Am J Cardiol, Nov 6;66(16):28G-31G.

18. Nordstrom, C.K., Dwyer, K.M., Merz, C.N., Shircore, A, Dwyer, J.H. (2001). Work-related stress and early atherosclerosis. Epidemiolog, Mar;12(2): 180-5.

19. Allison, T.G., Williams, D.E., Miller, T.D., Patten, C.A., Bailey, K.R., Squires, R.W., Gau, G.T. (1995). Medical and economic costs of psychologic distress in patients with coronary artery disease. Mayo Clin Proc, Aug;70(8):734-42.

20. Pender NJ. (1985). Effects of progressive muscle relaxation training on anxiety and health locus of control among hypertensive adults. Res Nurs Health, Mar;8(1) :67-72

21. Sharpley, C.F. (1994). Maintenance and generalizability of laboratory-based heart rate reactivity control training. Journal of Behavioral Medicine,17(3): 309-329).

22. Crowther, J.H. (1983). Stress management training and relaxation imagery in the treatment of essential hypertension. J Behav Med, Jun;6(2):169-87.

23. Taylor, C.B., Farquhar, J.W., Nelson, E. & Agras, S.(1977). Relaxation therapy and high blood pressure. Archives of General Psychiatry, 34: 339-42.

24. Zamarra, J.W., Schneider, R.H., Besseghini, I., Robinson, D.K., Salerno, J.W. (1996). Usefulness of the transcendental meditation program in the treatment of patients with coronary artery disease. Am J Cardiol, Apr 15;77(10):867-70.

25. Castillo-Richmond, A., Schneider, R.H., Alexander, C.N., Cook, R., Myers, H., Nidich, S., Haney, C., Rainforth, M., Salerno, J. (2000). Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans. Stroke. Mar;31(3):568-73.

26. Linden, W., Stossel, C., Maurice, J. (1996). Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med, Apr 8;156(7):745-52.

27. Oz, M.C., Lemole, E.J., Oz, L.L., Whitworth, G.C., Lemole, G.M. (1996). Treating CHD with Cardiac Surgery Combined with Complementary Therapy. Medscape Womens Health, Oct;1(10):7.

28. Lorig, K.R., Sobel, D.S., Stewart, A.L., Brown, Jr B.W., Ritter, P.L., Gonzalez, V.M., Laurent, D.D., Holman, H.R. (1999). Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care, 37(1): 5-14.

29. Ornish, D. (1998) Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. Am J Cardiol, 82:72T-76T.

Allison TG, Williams DE, Miller TD, Patten CA, Bailey KR, Squires RW, Gau GT. Medical and economic costs of psychologic distress in patients with coronary artery disease. Mayo Clin Proc. 1995 Aug;70(8):734-42.

American Heart Association. (2002). 2003 Heart and Stroke Statistics -- 2003 Update. Dallas, TX. American Heart Associatin. 2002. Pg. 12, 40. www.americanheart.org/downloadable/heart/10590179711482003HDSStatsBookREV7-03.pdf Accessed: June, 2006.

Baas A. MD. Chronic Ischemic Heart Disease in Best Practice of Medicine. 2001. Modified March 25, 2003. Accessed at Merck Praxis MD. http://merck.micromedex.com/index.asp?page=bpm_brief&article_id=BPM01CA05.
Accessed June, 2006.

Bairey CN, Krantz DS, Rozanski A. Mental stress as an acute trigger of ischemic left ventricular dysfunction and blood pressure elevation in coronary artery disease. Am J Cardiol. 1990. Nov 6;66(16):28G-31G.

Barefoot JC, Brummett BH, Helms MJ, Mark DB, Siegler IC, Williams RB. Depressive Symptoms and Survival of Patients with Coronary Artery Disease. Journal of Psychosomatic Medicine. 2000 Nov-Dec; 62(6): pp790-5.

Barnes VA, Treiber FA, Johnson MH. Impact of transcendental meditation on ambulatory blood pressure in African-American adolescents. American Journal of Hypertension. 2004 Apr; 17(4): pages 366-9.

Bijlani RL, Vempati RP, Yadav RK, Ray RB, Gupta V, Sharma R, Mehta N, Mahapatra SC. A brief but comprehensive lifestyle education program based on yoga reduces risk factors for cardiovascular disease and diabetes mellitus. J Altern Complement Med. 2005 Apr;11(2):267-74.

Boltwood MD, Taylor CB, Burke MB, Grogin H, Giacomini J. Anger report predicts coronary artery vasomotor response to mental stress in atherosclerotic segments. Am J Cardiol. 1993 72:1361-1365.

Castillo-Richmond A, Schneider RH, Alexander CN, Cook R, Myers H, Nidich S, Haney C, Rainforth M, Salerno J. Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans. Stroke. 2000 Mar;31(3):568-73.

Chang BH, Hendricks A, Zhao Y, Rothendler JA, LoCastro JS, Slawsky MT. A relaxation response randomized trial on patients with chronic heart failure. Journal of Cardiopulmonology and Rehabilitation. 2005 May-Jun; 25 (3): 149-57.

Crowther JH. Stress management training and relaxation imagery in the treatment of essential hypertension. J Behav Med. 1983 Jun;6(2):169-87.

Halpin LS, Speir AM, CapoBianco P, Barnett SD. Guided imagery in cardiac surgery. Outcomes in Management & Nursing Practice. 2002 Jul-Sep;6(3):132-7.

Herrmann JM. Essential hypertension and stress. When do yoga, psychotherapy and autogenic training help?] [Article in German] MMW Fortschr Med. 2002 May 9;144(19):38-41.

Ironson G, Taylor CB, Boltwood M. Bartzokis T, Dennis C, Chesney M, Spitzer S, Segall GM. Effects of anger on left ventricular ejection fraction in coronary artery disease. Am J Cardiol. 1993 70:281-285.

Lin MC, Nahin R, Gershwin ME, Longhurst JC, Wu KK. State of complementary and alternative medicine in cardiovascular, lung, and blood research: executive summary of a workshop. Circulation. 2001 Apr 24;103(16):2038-41.

Linden W, Stossel C, Maurice J. Psychosocial interventions for patients with coronary artery disease: a meta-analysis. Arch Intern Med. 1996 Apr 8;156(7):745-52.

Lorig KR, Sobel DS, Stewart AL, Brown Jr BW, Ritter PL, Gonzalez VM, Laurent DD, Holman HR. Evidence suggesting that a chronic disease self-management program can improve health status while reducing utilization and costs: A randomized trial. Medical Care. 1999 37(1): 5-14.

Mittleman MA, Maclure M, Sherwood JB, Mulry RP, Tofler GH, Jacobs SC, Friedman R, Benson H, Muller JE. Triggering of acute myocardial infarction onset by episodes of anger. Circulation. 1995 92:1720-1725.

Nakao M, Yano E, Nomura S, Kuboki T. Blood pressure-lowering effects of biofeedback treatment in hypertension: a meta-analysis of randomized controlled trials. Hypertension Research. 2003 Jan; 26(1): pages 37-46.

National Heart Blood and Lung Institute http://www.nhlbi.nih.gov/health/dci/Diseases/Cad/CAD_Summary.html. Accessed June, 2006.

Nordstrom CK, Dwyer KM, Merz CN, Shircore A, Dwyer JH. Work-related stress and early atherosclerosis. Epidemiolog. 2001 Mar;12(2): 180-5.

Ornish D, Scherwitz LW, Billings JH, Brown SE, Gould KL, Merritt TA, Sparler S, Armstrong WT, Ports TA, Kirkeeide RL, Hogeboom C, Brand RJ. Intensive lifestyle changes for reversal of coronary heart disease. JAMA. 1998 Dec 16;280(23):2001-7.

Ornish D. (1998). Love & Survival: The Scientific Basis for the Healing Power of Intimacy. New York, NY: HarperCollins.

Ornish D. Avoiding revascularization with lifestyle changes: The Multicenter Lifestyle Demonstration Project. Am J Cardiol. 1998c 82:72T-76T.

Orth-Gomer K, Wamala SP, Horsten M, Schenck-Gustafsson K, Shneiderman N, Mittleman MA. Marital stress worsens prognosis in women with coronary heart disease: The Stockholm Female Coronary Risk Study. JAMA. 2000 Dec 20; 284 (23): pp. 3008-3014.

Oz MC, Lemole EJ, Oz LL, Whitworth, GC, Lemole GM. Treating CHD with cardiac surgery combined with complementary therapy. Medscape Womens Health. 1996 Oct;1(10):7.

Pender NJ. Effects of progressive muscle relaxation training on anxiety and health locus of control among hypertensive adults. Res Nurs Health. 1985 Mar;8(1) :67-72.

Sharpley CF. Maintenance and generalizability of laboratory-based heart rate reactivity control training. Journal of Behavioral Medicine.1994 17(3): 309-329).

Sheps DS, McMahon RP, Becker L, Carney RM, Freedland KE, Cohen JD, Sheffield D, Goldberg AD, Ketterer MW, Pepine CJ, Raczynski JM, Light K, Krantz DS, Stone PH, Knatterud GL, Kaufmann PG. Mental stress-induced ischemia and all-cause mortality in patients with coronary artery disease: Results from the Psychophysiological Investigations of Myocardial Ischemia study. Circulation. 2002 Apr 16;105:1780–1784.

Taylor CB, Farquhar JW, Nelson E & Agras S. Relaxation therapy and high blood pressure. Archives of General Psychiatry. 1977 34: 339-42.

Van Dixhoorn J, White A. Relaxation therapy for rehabilitation and prevention in ischaemic heart disease: a systematic review and meta-analysis. Eur J Cardiovasc Prev Rehabil. 2005; June;12(3):193-202.

Vyas R, Dikshit N. Effect of meditation on respiratory system, cardiovascular system and lipid profile. Indian J Physiol Pharmacol. 2002 Oct;46(4):487-91.

Verrier RL, Hagestad EL, Lown B. Delayed myocardial ischemia induced by anger. Circulation. 1987 5:249-254.

Verrier, RL, Mittelman MA. Cardiovascular consequences of anger and other stress states. Baillieres Clin Neurol. 1997 Jul;6(2):245-59.

Williams R, Kiecolt-Glaser J, Legato, MJ, Ornish D, Powell LH, Syme SL, Williams V. The impact of emotions on cardiovascular health. The Journal of Gender-Specific Medicine. 1999 2[5]:52-58.

Zamarra JW, Schneider RH, Besseghini I, Robinson DK, Salerno JW Usefulness of the transcendental meditation program in the treatment of patients with coronary artery disease. Am J Cardiol. 1996 Apr 15;77(10):867-70.