107th Congress

Report: Stress and Heart Disease—Hearing Before the Senate Appropriations Subcommittee on Labor, Health and Human Services, Education—May 16, 2002

Members Present

Senator Arlen Specter (R-PA), Ranking Minority Member.

Witnesses

Panel One: Peter Kaufman, Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute (NHLBI), NIH

Panel Two:

• David Abrams, Professor, Psychiatry and Human Behavior, Brown Medical School
• Herbert Benson, President, Mind/body Medical Institute
• Harvey Eisenburgh, Director, Healthview
• Dean Ornish, President and Director, Preventive Medicine Research, Inc.
• Marina Vernalis, Medical Director, Cardiac Risk Prevention Center, Walter Reed Hospital
• Karen Matthews, Director, Cardiovascular Behavioral Medical Research Training Program, University of Pittsburgh School of Medicine.

Purpose of Hearing: The hearing was held at the request of Senator Specter to hear testimony from the range of experts on the impact of stress on heart disease and what might be done to reduce the risk.

Summary

The witnesses agreed that the reduction of stress would be a positive step in preventing or treating heart disease. Witnesses also agreed that other lifestyle modifications such as attention to diet, exercise, and other factors were all important. NHLBI and others acknowledged that there have been no definitive controlled clinical studies that address the impact of stress reduction alone, apart from the other interventions that are more commonly undertaken such as heart healthy diets and the initiation of exercise programs.

Opening Statements

Senator Specter noted that despite the many hearings his Subcommittee has held, there has never been a hearing on this specific topic. He said it was of personal interest to him.

Statements of Witnesses

Dr. Kaufmann stated that while there is evidence that some individuals respond in negative ways to stress, it has not been conclusively proved in randomized clinical trials that stress reduction can ensure a positive result for a patient at risk. In his testimony, he said that data suggests that stress management interventions might improve the clinical status of certain patients who have demonstrated that mental stress and emotions, such as anger, can cause myocardial ischemia or reduced blood flow through the heart. Patients who respond to mental stress with myocardial ischemia are called mental stress positive. Furthermore, it is generally acknowledged that the results of completed trials are preliminary, in part because they combine stress management with other rehabilitation strategies, making it difficult to determine the relative contributions of various interventions and for other reasons of clinical trial design. He also noted that the question of whether stress management can reverse heart disease is of considerable interest. Aggressive lowering of blood cholesterol levels with lipid lowering drugs can slow progression of atherosclerosis and improve vascular function and blood flow through the heart and reduce heart attacks. While a small number of clinical trials involving intensive dietary modification have shown similar success, it is not possible to know to what extent stress management contributed to the observed results. In summary, he recommended that a well-designed clinical trial is needed to evaluate the potential of stress management in cardiac rehabilitation. However, because acute stress can trigger cardiac events and initial results from clinical trials seem promising, it is also prudent to include stress management in cardiac rehabilitation programs for patients who want these interventions.

Dr. Abrams stated that acute stress can precipitate cardiac problems and can also interfere with both providers' and patients' ability to adhere to medical recommendations. He, too, said that it is hard to separate out the effects of stress alone on heart disease. Usually, stress management is combined with other lifestyle and medical components in a total package to reduce heart disease. He, therefore, urged that combined medical, lifestyle and stress management can make a measurable impact on preventing or reversing the progression of heart disease, which is most dramatic if begun as early as possible in the disease process.

Dr. Benson discussed his research on the role of stress and its role in cardiovascular disease. He recommends the use of the relaxation response techniques to counteract stress. Dr. Eisenburgh discussed the full body scan for early disease detection, which he is developing with the support of the U.S. Department of Defense funding and backing of Senator Ted Stevens (R-AK).

Dr. Ornish focused on the importance of treating the underlying causes of heart disease. He said that with change in diet, lifestyle and effective stress management, there are more effective biological measures for stress and one doesn't have to wait years to see the improvement.

Dr. Matthews stressed three points:

• Psychological stress can trigger heart attack and lead to premature death. It may also accelerate the rate of atherosclerosis in the coronary arteries prior to the first heart attack.
• There are relatively few clinical trials of stress management that meet standard criteria for clinical trials with heart disease patients. However, combining the data from smaller-scale clinical trials does show that psychosocial interventions are a useful adjunct to standard care.
• The science of behavior change, and practical knowledge on how to conduct clinical trials has advanced sufficiently. Now is a good time for larger-scale studies to evaluate how we can best promote health in coronary patients as well as prevent the first occurrence of heart disease.

Questions

• There has been an enormous increase in NIH, generally, from $12 billion to $23 billion; and the President has asked for $3.4 billion. I know you have some limitations within the protocol of NIH, but is there an adequate allocation to the research on the kinds of subjects we're discussing here today? I would like to have the views of the participants on the panel as to where you would like to see NIH go, beyond where NIH is today. I would broaden the question beyond NIH to CDC.
• (Dr. Ornish to Dr. Kaufmann) I'm just curious to know what the percentage of NIH funding goes to these kinds of approaches.
• I would like to hear from each of you as to an abbreviated suggestion to the man on the street on the issue of stress management. What would you say as to what he or she should do as a first step if they can't undertake one of the wonderful programs a week with Dr. Ornish or a week with Dr. Vernalis?
• I'd like your comments on how we educate the man on the street as to these issues. What might NIH be doing, or CDC, or, perhaps, the U.S. Department of Education?
• I would like you to supplement your oral testimony in two respects:
• I would like you to give the subcommittee, in writing, what you think NIH should be doing that NIH is now not doing. Feel free to specify your own pet projects that you might want to apply for grants. Broaden it, actually, beyond NIH to CDC or DARPA.
• I'd like your written views on how does this message get out to the man on the street? We have resources at our disposal to get the message out and have some direction to NIH, CDC, DARPA or HHS. Dr. Ornish, when you made the comment about what is reimbursed, that could be included in part one because we have some influence with Medicare in HHS.

Prepared by Anne Houser, OLPA, June 3, 2002